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Harvey Cushing / John Hay Whitney 
Medical Library 

HISTORICAL LIBRARY 




Yale University 



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THE BOSTON 

MEDICAL AND SURGICAL 

JOURNAL 



GEORGE B. SHATTUCK, M.D., 
ABNER POST, M.D., 
CHARLES F. WITHINGTON, M.D., 
ALGERNON COOLIDGE, Jr., M.D., 



Editors 

Assistant Editors 



VOLUME CXXIII 



JULY — DECEMBER, 1890 



BOSTON 

DAMRELL AND UPHAM 

283 Washington Street 
1890 



PRESS OP S. J. PARKHILL & COMPANY, 
222 FRANKLIN STREET, 
BOSTON. 




■Jb i 



CONTRIBUTORS TO VOLUME CXXIII. 



ABBOT, S. L., M.D. 
ABBOTT, SAMUEL W., M.D. 
ALLEN, GARDNER W., M.D. 
ATKINS, E. C, M.D. 
BEACH, H. H. A., M.D. 
BILLINGS, JOHN S., M.D. 
BIRGE, W. S., M.D. 
BLAKE, CLARENCE J., M.D. 
BLODGETT, ALBERT N., M.D. 
BO WEN, JOHN T., M.D. 
BRADFORD, EDWARD H., M.D. 
BROWN, FRANCIS H., M.D. 
BUCKINGHAM, EDWARD M., M.D. 
BURRAGE, W. L., M.D. 
BURR ELL, HERBERT L., M.D. 
CABOT, A. T., M.D. 
CHADWICK, JAMES R., M.D. 
CHANDLER, H. B., M.D. 
CLEVENGER, S. V., M.D. 
COGGIN, D., M.D. 
COOK, GEORGE, M.D. 
COOLIDGE, ALGERNON, Jr., M.D. 
COLT, HENRY, M.D. 
COTTING, BENJAMIN E., M.D. 
CUSHING, E. W., M.D. 
CUTLER, E. G., M.D. 
DANA, ISRAEL T., M.D. 
DAVENPORT, B. F., M.D. 
DAVENPORT, F. H., M.D. 
DWIGHT, THOMAS, M.D., LL.D. 
EVERETT, W. S., M.D. 
FARLOW, JOHN W., M.D. 
FISHER, C. IRVING, M.D. 
FITZ, R. H., M.D. 
FOLSOM, CHARLES F., M.D. 
FORSTER, EDWARD J.. M.I). 
FRENCH, J. M., M.D. 
GARC EAU, EDGAR, M.D. 
GAY, GEORGE \V.. M.D. 
GIBBES, HENEAGE, M.D. 
GOLDTHWAIT, JOEL E., M.D. 
GRAHAM, H., U.S.A. 
GREEN, CHARLES M., M.D. 
HALL, J. N., M.D. 
HARRINGTON, ARTHUR H.. M.D. 
HARRINGTON, F. B., M.D. 
HERSEY, GEORGE D., M.D. 
HILLS, WILLIAM B., M.D. 
HOMANS, JOHN, M.D. 
HOMANS, JOHN, -2nd, M.D. 
HOOPER, FRANKLIN H., M.D. 
HURD, E. P., M.D. 
HUSE, R. C, M.D. 
INGALLS, WILLIAM, M.D. 



IRISH, J. C, M.D. 
JACK, FREDERICK L., M.D. 
KNAPP, PHILIP COOMBS, A.M., M.D. 
LEWIS, H. F., M.D. 
LOVETT, ROBERT W., M.D. 
LYMAN, GEORGE H., M.D. 
MANLEY, THOMAS H., M.D. 
MEIGS, JOE V., M.D. 
M I NOT, CHARLES SEDGWICK, S.D. 
.Ml NOT, FRANCIS, M.D. 
MIXTER, S. J., M.D. 
MONKS. G. H., M.D. 
MOULTON, A. R., M.D. 
NEWELL, OTIS K., M.D. 
PALMER, JULIUS A., Jr., M.D. 
PERKINS, JOHN W., M.D. 
PFEIFFER, O. J., M.D. 
PINEO, PETER, M.D. 
PORTER, C. B., M.D. 
POST, ABNER, M.D. 
PRINCE, MORTON, M.D. 
PUTNAM, J. J., M.D. 
RICHARDSON, MAURICE H., M.D. 
ROTCH, T. M.. M.D. 
SCUDDER, CHARLES L., M.D. 
SEARS, GEORGE G., M.D. 
SEEGEN, I., M.D. 
SEGUIN, E. C, M.D. 
SHATTUCK, F. C, M.D. 
SHATTUCK, GEORGE B., M.D. 
SHERMAN, T. F., M.D. 
SHURLY, E. L., M.D. 
SMITH, W. EVERETT, M.D. 
SPRING, CLARENCE W., M.D. 
STANDISH, MYLES, M.D. 
STEDMAN, C. E., M.D. 
STEPHENSON, F. B., M.D., U.S.N. 
STETSON, GEORGE R., M.D. 
STONE, A. K., M.D. 
STRONG, CHARLES P., M.D. 
TAYLOR, HENRY LING, M.D. 
TOWNSEND, CHARLES W., M.D. 
TYNDALE, J. HILGARD, M.D. 
URIE, J. F., M.D.. U.S.N. 
VICKERY, HERMAN F., M.D. 
WADSWORTH, O. F., M.D. 
WALTON, G. L., M.D. 
WENDT, E. C, M.D. 
WHEELER, LEONARD, M.D. 
WHITTIER, E. N., M.D. 
WILBUR, H. G., M.D. 
WILLIAMS, FRANCIS H., M.D. 
WILMARTH, JEROME, M.D. 
WITHINGTON, C. F., M.D. 



INDEX TO VOLUME CXXIII. 



Abbe, K. Spinal surgery, a report of eight cases, C3, 86. 

Abbot, S. L. Cases of cystitis treated with salol, 57. 

Abbott, S W. What constitutes a tilth-disease ? 621. 

Abdominal Surgery. Largo papillomatous cyst with ascites, lap- 
arotomy, wound of tho bladder which lay unusually high, suture of 
it with complete recovery, Cabot, A. T., 83, 84; an unsuccessful 
case of digital dilatation of the pylorus for cicatricial stenosis, 
Cutler, E. G., and Richardson, M. 11., 681, 592. 

Abortion. Treatment of abortions, Baldwin, H. C, 423. 

Abscess. The treatment of cold abscesses without drainage, with 
report of cases, Lovett, It. VV., 272. 

Africa. A physician's notes in Central Africa, 45. 

Allen, C. VV. The treatment of erysipelas, 255 ; aristol, 255. 

Allen, G. W. Some points in the treatment of gonorrhoea, 121, 132. 

Altehoef fer. Peroxide of hydrogen as a disinfectant of water, 477. 

Amputation at the shoulder-joint for sarcoma, Porter, C. B., 1*1 ; 
amputation as an orthopedic measure, Vance, A. M., 303; double 
primary and actually synchronous amputation of the lower ex- 
tremities, with recovery, Irish. J. C, 616. 

Anaemia. On the treatment of anaemia, 280. 

Auaesthesia. The value of primary anaesthesia in minor surgical 
operations, Harrington, F. B., 434. 

Anatomy. Demonstration of some special characteristics in the 
brain of a distinguished scientist, Wilder, B. J., 89 ; the scope and 
the teaching of human anatomy, Dwight, T., 337, 391 ; recent pro- 
gress in anatomy, Dwight, T., 391. 

Andrews, J. A. Purulent ophthalmia, 159 ; cystlike bodies of the 
conjunctiva, 159. 

Antiseptics and anaesthetics at Berlin, 234 ; antisepsis and asepsis 
in surgery, 25S ; antiseptics and ether, Coggin, D., 358 ; the com- 
parative value of biniodide and bichloride of mercury as surgical 
antiseptics, Jewett, C, 443 ; the application of antiseptic methods 
in midwifery practice, McMurtry, L. S.,448 ; disinfection of the 
hands, Ball, 452; wet antiseptic dressings in injuries of the hand, 
Nicolson, W. P., 568. 

Annus Medicus MDCCCXC, 622. 

Appendicitis, operation, hernia, recovery, Stedman, C. E., 299, 302 ; 
appendicitis, operation, Garceau, E.,438; appendicitis, Gay, G. W., 
557; appendicitis, typhlitis and perityphlitis in children, Smith, 
J. L., 564; two cases of relapsing appendicitis, operation between 
attacks, removal of appendix, recovery, Porter, C. B., 611. 

Army. Some aspects of our medical service in the War of the Re- 
bellion, Lyman, G. H., 145, 169 ; the new sui geon-general, 210 ; the 
fifth distribution of arms and legs to veterans, 333; an army sur- 
geon's tour of duty with State troops, 574. 

Arsenic. The hypodermic use of arsenic, Moyer, H. N., 447 ; a case 
of multiple neuritis due to arsenic, Cutler, E. G., 463. 

A sell. M. J. A new operation for deviation of the nasal septum, 12. 

Asliby, T. A. Laparotomy for intra-pelvic pain, 444 ; drainage 
after laparotomy, 422. 

Atkins, E. C. Colorado as a health resort, 390. 

Autopsies in America, 449. 

Babinsky. Erysipelas as a cure for diphtheria, 453. 

Bacillus. The poison of bacilli, Brieger and Fraenkel, 430 ; tuber- 
cle bacilli, Gibbes, H., and Shurly, E. L., 487 ; clinical value of the 
bacillus of tuberculosis, Stone, A. K., 515. 

Baker. Address before the American Public Health Association, 
620. 

Bald-win, H. C. Treatment of abortions, 423. 
Baldy, J. 31. Ectopic pregnancy, 351. 

Ball. Disinfection of the hands, 452 ; breaking the opium habit, 477 
Barclay, K. Dr. Blake's paper disk, case histories, 113. 
Barry, C. Poisoning in the Bombay presidency, 234. 
Baxter, G. A. Silicate of soda, some new methods of use in sur- 
gery, 569. 

Beach, H. H. A. A neuroplastic operation, designed for the restor- 
ation of nerve trunks that have been destroyed by injury or dis- 
ease, 562. 

Becker. A new and rapid test for sugar, 309. 

Belfield, W. T. Notes on the technique of suprapubic cystotomy 
and prostatectomy, 15 ; resume of experience to date, all over the 
world, in the various operations for cystitis from prostatic hyper- 
trophy, 447. 

Beri-beri. Multiple neuritis or beri-beri among seamen, Putnam, 
J. J., 62; a form of polyneuritis, probably analogous to or identical 
with beri-beri, occurring in seafaring men in Northern latitudes, 
Putnam, J. J., 244; beri-beri on fishing vessels from the Grand 
Banks, 427 ; cases of beri-beri occurring in the Provincetown 
Grand Bank fishing fleet, Birge, W. S., 464. 



Berlin. The Berlin International Congress, 188, 212, 213, 214, 237, 
288, 309 ; the Berlin water and sewage works, lb9 ; antiseptics and 
anaesthetics at Berlin, 234 ; en route to Berlin, 526. 

Bibliography. Allingham, H. W., the treatment of internal de- 
rangements of the knee-joint by operation, 163; American Surgical 
Association, transactions. Vol. VI, 65; army, surgeon-general's 
office, index catalogue, Vol. XI, 449; Ashley, II., the diseases of 
children, medical and surgical, 230; Ashhurst, J., Jr., the princi- 
ples and practise of surgery, 185; Ashton, W. E., Saunder's question 
compeuds, No. 5, 207 ; Association of American Physicians, trans- 
actions, IV, 328; Bastin, E. S., college botany, including organogra- 
phy, vegetable histology, physiology and taxonomy, with a brief 
description of the succession of plants in geologic time and a glos- 
sary of botanical terms, 448; Bernheini, H., suggestive therapeutics, 
a treatise on the nature and uses of hypnotism, 65; Bourueville 
and others, recherches cliniques et therapeutiques sur l'epilepsie, 
l'hysterie et l'idiotie, 114; Bowlby, A. A., injuries and diseases of 
nerves, and their surgical treatment, 164; Bradford, E. H., and 
Lovett, R. W., a treatise on orthope ic surgery, 186; Doty, A. H., a 
manual of instruction in the principles of prompt aid to the in- 
jured, designed for military and civil use, 163; enquete sur la 
grippe, 279; Fullerton, A. M., a hand-book of obstetrical nursing, 
for nurses, students and mothers, 230; Garretson, J. E., a system of 
oral surgery, being a treatise on the diseases and surgery of the 
mouth, jaws, face, teeth and associate parts, 401; Graham, D., 
massage kort framstullning, 163; Heath, C, a manual of minor 
surgery and bandaging for the use of house-surgeons, dressers and 
junior practitioners, 163; Hirst, B. C, a system of obstetrics by 
American authors, 596; Hurd, E. P., a treatise on neuralgia, 164; 
James, "W., the principles of psychology, 696; Keating, J. M,, cyclo- 
paedia of the diseases of children, medical and surgical, 17, 621: 
Kraft't-Ebing, D. R. von, an experimental study in the domain of 
hypnotism, 17; Massachusetts Board of Health, report, 547; Mas- 
sey, G. B., electricity in the diseases of women, 207; Maxwell, T., 
terminologia medica polyglotta, 256; medical bulletin visiting list, 
622; Morris, M., international atlas of rare skin diseases, 400; Nor- 
ris, R. C, syllabus of the obstetrical lectures in the medical depart- 
ment of the University of Pennsylvania, 230; Obersteiner, H., the 
anatomy of the central nervous organs in health and disease, 162; 
Osier, W., the cerebral palsies of children, 229; Owen, E., a man- 
ual of anatomy for senior students, 231; Page, R. C, a hand-book 
of physical diagnosis of diseases of the organs of respiration and 
heart, and of aortic aneurism, 231; Pellizzari, G., archivo della 
scuola d'anatomia patologica diretto, 138; physician's visiting list, 
546; Playfair, W. S., a treatise on the science and practice of mid- 
wifery, 1/4; Rankin, F. H., hygiene of childhotd, suggestions for 
the care of children after the period of infancy to the completion 
of puberty, 186; Rau, L. S., May's diseases of women, being a con- 
cise and systematic exposition of the theory and practice of gyne- 
cology, for the use of students and practitioners, 256; Robinson, D. 
H., the Latin grammar of pharmacy and medicine, 474; Sayre, L. 
E., essentials of practice of pharmacy, 546; Seibert, W. A., the 
physician's all-requisite time- and labor-saving account book, 546; 
Senn, N., surgical bacteriology, 185; Sevestre, etudes de cliuique 
infantile, 230; Shoemaker, J. V., ointments and oleates, especially 
in skin diseases, 401; Sterling, W., outlines of practical histology, 
186; Tait, L., diseases of women and abdominal surgery, 162; Tooth, 
H. H., the Gulstonian lectures on secondary degenerations of the 
spinal cord, 114; Watson, B. A., an experimental study of lesions 
arising from severe concussion, 229. 

Bigelow, II. J., 450, 474, 480, 553. 554 ; the memorial meeting of the 
Boston Society for Medical Improvement, 505 ; Bigelow as a sur- 
geon, Cabot, A.T.,510; Henry Jacob Bigelow, M.D., Fitz, R. H., 
511; Dr. Bigelow and the introduction of ether, Pineo, P., 554; the 
claim that the merit of introducing ether belongs to Dr. Henry J. 
Bigelow, Dwight, T., 553; resolutions of the Medical Board of the 
Massachusetts General Hospital, 602. 

Biography. Allen, C. L., 48; Allen, J. A., 216; Batchelder, D. H., 
264; Baxter, J. H., 210, 678; Bigelow, H. J., 450, 474, 480, 553, 554, 
602; Bishop, E. H., 360; Blakeman, W. N., 189; Borland, J. N., 168; 
Brace, C. L., 189; Culbertson, H., 24; Davidson, H. E., 190; De- 
Wolff, T. K., 480; Doe, O. W., 601; Gleason, J. C, 456; Gregory, J. 
E.,454; Griggs, T. T., 216; Griscom, J. D., 144; Gruber, W., 404; 
Hardy, E., 404; Hubbell, C. L., 360; Kingsley, G. L., 336; Lehman, 
G. C. H., 404; Levis, R. J., 504; Manwaring, R. A., 264; Mosher, C. 
D., 336; Murphy, J., 288; Monod, G., 549; Niles, D. W., 96; Nuss- 
baum, 549; Passmore, E. C. 165; Patten, M. A., 360; Peck, W. D., 
48; Roberts, J., 120; Sharp, J. C, 360; Smith. W. E., 72, 149; Spring, 
C. E.,432; Starr, J. H.,140; Stevens, W. F., 264, 336; Stewart, J. L., 



vi 



INDEX TO VOLUME OXXIII. 



604; Swett, Samuel, 580; Taylor, I. H.,408; Thayer, P., 360; Thom- 
son, C. S., 192; Vogel, A., 549; Wilmarth, J., 360. 
Birdsall, W. R. Remarks on therapeutics as applied to nervous 
disorders, 91. 

Birge, W. S. Cases of beri-beri occurring in the Provincetown 

Grand Bank fishing fleet, 464. 
Blake, C. J. The Boston City Hospital, 1. 

Blodgett, A. N.- The continuous inhalations of oxygen in cases of 
pneumonia otherwise fatal, and in other diseases, 481, 493. 

Blood. The pathology of the blood, 498. 

Boldt, H. J. Inoculations for pulmonary tuberculosis, 567. 

Bone. Usteo-chrondro-myxoma of the right thigh, Whitney, W. F., 
85 ; some observations on bone and skin grafting, Cavana, M., 523. 

Bordas. On the transmission of typhoid fever by the air, 141 ; 
mumps, 477. 

Boston City Hospital, Blake, C. J., 1. 

Bosworth, F. A case of unilateral paralysis of the abductors of 
the larynx, the result of an attack of bulbar disease, with unusual 
symptoms, 36. 

Bouveret. Paroxysmal pulmonary oedema in chronic albuminuria, 

Bowen, J. T. Cases of cutaneous tuberculosis with histological 
studies, 254; report on progress in dermatology, 562, 589. 

Brajford, E. H. The treatment of lateral curvature, 250, 327; 
the treatment of deformities of spastic paralysis, 303 ; the surgical 
treatment of spastic paralysis in children, 485. 

Bradford, E. H., and Lovett, R. W. Report on the recent pro- 
gress of orthopedic surgery, 439, 461; congenital deformity of the 
nose, 586. 

Bronaon, E. B. A study on pruritus, 253. 

Brown, B. The local and general treatment of gangrenous wounds 
and diseases, 545. 

Brown, F T. A case of severe ha;maturia, nephrectomy by Dr. 
McBurney, recovery, 14. 

Browne, Li. Faucial and pharyngeal tenesmus, 477. 

Buchner. Pyogenic materia' within bacterial cells, 551. 

Buck, A. H. Ou the renewed employment of the nasal douche and 
kindred procedures, 111. 

Buckingham, E. M. Influenza in the out-patient service of the 
Boston City Hospital, 343, 348 ; unnecessary noise an avoidable 
evil in cities, 430. 

Bulkley, L.. D. Clinical notes on lichen planus, 495. 

Bull, C. S. The extraction of dislocated lenses from the eye, 
whether transparent or calaractous, 136; some further considera- 
tions on the •' simple operation " for the extraction of cataract, 136. 

Burnett, C. H. Permanently good results of excision of the mal- 
leus and membrana tympani in a case of chronic tinnitus and aura! 
vertigo, ami in a case of chronic suppuration of the attic due to 
necrosis of the malleus, 112. 

Bni raje, W. Li. Another needle forceps, 274. 

Burrell, H. L., and Cu?hing, H. W. Report on recent progress 
in surgery, 319. 

Bursa. A case of enlarged subcutaneous bursa in front of the tuber- 
cle of the tibia, Monks, G. H., 591, 592. 

Byford, H. Vaginal fixation of the stump in abdominal hysterec- 
tomy, 398. 

Cabot, A. T. A case cf cystitis, with the formation of a thick epi- 
dermal sheet in the bladder, 14 ; a case of cyst of the kidney ap- 
parently cured by a single aspiration, 39 ; a case of extrophy of the 
bladder, with photographs, 39 ; large papillomatous cyst with 
ascites, laparotomy, wound of the bladder which lay unusually 
high, suture of it with complete recovery, 83, 84 ; piece of catheter 
in the blad ier, S4 ; a successful case of uretero-lithotomy for an 
impacted calculus, 247 ; old anterior dislocation of the humerus, 
252 ; dermoid cyst of the ovary, 278 ; forward dislocation of one of 
the carpal bones, 443 ; Bigelow as a surgeon, 510 ; notes on the non- 
operative treatment of enlarged prostate, 529, 537; another success- 
ful case of uretero-lithotomy, 613. 

Caldwell, W. H. Rectal medication, 570. 

Cancer. Recent speculations as to the nature of cancer, the electro 

lytic treatment of cancer, 18. 
Carmalt, W. H. A contribution to ocular tumors, 160. 
Carpus. Forward dislocation of one of the carpal bones, Cabot, A. 

T., 443. 

Cavana, M. The physician as a witness, 523. 

Cederschiold. Manipulation of the nasal mucous membrane, 577. 
Cephalhematoma, Kelly. H. A., 421. 

Chadwick, J. K. Two cases of hydatidiform mole, 423 ; two cases 
Of tumors coincident with pregnancy, 424; chlorate of potassium 
as a preventive of intra-uterine death, 424 ; two cases of pregnancy 
complicated with tumors, 532. 

Chancellor, C. W. How diphtheria is spread by corpses, 166. 

Chancre. Curetting the soft chancre, Petersen, 476. 

Chandler, H. B. Report of fifty cataract extractions by a new 
method, 

" Changing- doctors," 19. 

Chapin, H. S. Hygiene in the public schools, 472. 

Chase, VV. D. Diff use calcification of the muscular system in a 
case of fracture, 158. 

Chemistry. Report on medical chemistry, Hills, W. B., 6. 

Children. Report on diseases of children, Rotch, T. M.,103, 587, 614; 
pericarditis in childhood, Knoff, 380; stomach washing in very young 
children, Froitzky, 453 ; the surgical treatment of spastic paralysis 
in children, Bradford, 15. H., 485; appendicitis, typhlitis and peri- 
typhlitis in children. Smith, J. L., 564; hydrocele in children, with 
a report of cases, Lovett, R. W., 584, 592; Boston Children's Hos- 
pital, 600. 

Child-wife murder, 332. 

China. Chinese medical practice and practitioners, Thomson, J. 
C, 501. 

Chloroform. Decomposition of chloroform by artificial light, 

Kiinke), 453. 

Cholera in Spain, Santa, D. P.. 94 ; cholera in Spain, 261. 

Chorea. Unusual forms of chorea, possibly of spinal origin, 
Mitchell, S. W., and Burr, C. H., 41. 

Circulatory System. Eight cases of large, pulsating arteries on 
the posterior wall of the pharynx, Farlow, J. W.,6; a case of 
malignant endocarditis secondary to colitis, remarks, Shattuck, 



F. C, 79, 84 ; malignant endocarditis, death, autopsy, Stedman, C. 
E., 82, 84 ; cardiac dyspnoea, 91 ; the insanity of cardiac disease. 
115 ; heart failure, Whittier, E. N., 222, 227 ; hematoma of the 
sterno-cleido mastoid muscle, Judson, A. B., 274 ; a case of consid- 
erable cerebral haemorrhage without symptoms, Shattuck, G. B., 
324 ; pericarditis in childhood. Knoff, 380 ; torsion of arteries as a 
means for the arrest of haemorrhage, Murdoch, B., 420 ; cephal- 
hematoma, Kelly, H. A., 421. 
Clevenger, S. V. Erichsen's disease as a form of the traumatic 
neuroses, 217. 

Climate. Some of the relations of climate to health and disease, 
Smith, W. E., 149, 173 ; is the mortality after gynecological opera- 
tions affected by climatic influences? Coe, H. C, 421. 

Club-foot. Method of dealing with club-foot, Morton, T. G., 327. 

Coats or shirt-sleeves, 68. 

Cobb, W. H. H. Suprapubic cystotomy in a case of enlarged pros- 
tate, 544. 

Cocaine analgesia, its extended application in general surgery, 
when hypodermically employed, 458 ; laparotomy under cocaine. 
501. 

Coccyodynia. A case of coccyodynia, removal of coccyx, recovery , 
Post, A., 300. 

Coe, H. C. Is the mortality after gynecological operations affected 

by climatic influences ? 421. 
Coffee, Love, 1. N., 418. 

Coggin, D. Iodide of sodium and iodide of potassium, 47 ; antisep- 
tics and ether, 358. 
Cohen, S. S. Look beyond the nose, 11. 

Colles' fracture, with especial reference to treatment, Huse, R. C, 
77. 

Colorado as a health resort, Atkins, E. C, 390. 
Colt, H. Obstetrical work in a cottage hospital, 386. 
Conn, G. P. Railway hygiene, 155. 

Consumption in Massachusetts, French, J. M., 340 ; Stetson, G. R., 
454. 

Cook, G. Three cases of surgery, 157 ; a case of rhinoplasty, 226. 
Corlett, W. T. A clinical study of pruritis hemialis, winter itch, 

frost itch, etc., 253. 
Coroner. The medical examiner vs. the coroner, 500. 
Cottage hospitals. Obstetrical work in a cottage hospital, Colt, 

H., 386 ; the responsibilities and legal dangers of cottage hospitals, 

425. 

Cotting, B. E. Ca-es in which the disease indicated by the symp- 
toms was not found on post-mortem examination, why doctors may 
be non-committal sometimes, 457. 

Cough, its relation to infra-nasal disease. Thrasher, A. B., 419. 

Country doctor, 43; Wilmarth, J., 142 ; road-help for the country 
doctor, Potter, 551. 

Crai/iectomy for microcephalic cretinism, Wendt, E. C, 233. 

Cretinism. Craniectomy for microcephalic cretinism, Wendt, E. 
C, 238. 

Cronyn, J. Prognostics in medicine, 468. 

Clashing, B. A case of obstruction of the bowel, 326. 

Cushing, E. W. The Berlin Congress, 214, 2(<5. 

Cutaneous System. Case cf epithelial cancer in a negress, Forster, 
E. J., 58; address before the American Dermatological Associa- 
tion, Morrow, P. A., 252; observations on prurigo, clinical and 
pathological, Taylor, R. W., 253 ; a clinical study of pruritus hemi- 
alis, winter itch, frost itch, etc., Corlett, W. T., 253 ; cases of cuta- 
neous tuberculosis with histological studies, Bowen, J. T., 254 ; 
remarks on the treatment of dermatitis herpetiformis, Duhring. 
L. A., 254 ; a case of atropia maculosa et striata following typhoid 
fever, Shepherd, F. J., 254; immigrant dermatoses, White, J. C, 
254; a case of second infection with syphilis, and a case of syph- 
ilitic infection iai a person hereditarily syphilitic, Taylor, R. W., 
255; electrolysis in the treaunent of lupus vulgaris, Jackson, G. 
T., 255 ; plica, Stelwagon, H. W., 255 : the tieatnient of erysipelas, 
Allen. C. W., 255 ; aristol, Allen, C. W., 255 ; notes on pilocarpine 
in dermatology, Klotz, H. G., 255 ; the treatment of dermatological 
cases by sulphur water at Richfield Springs, Ransom, C. O, 255 ; 
the use of skin from puppies in skin-grafting, Van Meter, M. E., 
282 ; eczema from the use of creolin, 309 ; clinical notes on lichen 
planus, Bulkley, L. D.,495; some observations on bone and skin 
grafting, Hicketts, B. M., 523; report on progress in dermatology, 
Bowen, J. T., 562, 589. 

Cutler, E. G. A case of multiple neuritis due to arsenic, 41 3, 465 ; 
a case of pseudo-muscular hypertrophy in an adult, 465. 

Cutler, E. G., and Richardson, M. H. An unsuccessful case of 
digital dilatation of the pylorus for cicatricial stenosis, 581, 592. 

Dalton, II . C. Cases of penetrating stab-wounds of the abdomen, 
laparotomy, results, 419. 

Dana, C. L. Chronic softening of the cord, senile paraplegia, 42 ; 
on ingravescent apoplexy, 88. 

Dana, I. T. Seizures characterized by shock and sudden coma, 289. 

Davenport, B. F. Food, drugs and their adulterations, 180. 

Daveiaport, F. H. Report of progress in gynecology, 153 ; a case of 
vaginal hysterectomy, 20(1, 202 ; vesical calculus removed by vaginal 
lithotomy, 204 ; incontinence of urine due to malposition of the 
ureter, 420. 

Death. The diaphanous test of death, Richardson, B. VV., 332. 
Decidua. On the fate of the human decidua reflexa, Minot, C. S., 
561. 

Decollete in medical practice, 306. 

Delavan, D. B. On the early diagnosis of malignant disease of the 
larynx, 37. 

Dencke. A case of tubercle inoculation, 381. 

Dercum, F. X. A case of complete paraplegia cured by trephining, 
61. 

Diabetes. The treatment of diabetes, Pavy, F. W., 236 ; the treat- 
ment of diabetes mellitus, Seegen, L, 265 ; a new and rapid test for 
sugar, Becker, 309. 

Diagnosis. A plea for physical diagnosis, Tyndale, T. H.,249. 

Digestive System. An instrument lor removing glandular hypei - - 
trophies from the tongue, Hoe, J. O., 12 ; wire-loop curette for re- 
moving adenoid new growth from the pharynx, Ilolden, E., 12 ; a 
case of stricture of the GftSOphagUfi from interstitial thickening of 
its walls. Roe, J. O., 37 ; a case of acute pancreatitis, 46 ; obferva- 
tious on a case of perityphlitis, Honians, j.,2nd, 81, 84 ; a successful 



INDEX TO VOLUME OXXIII. 



vii 



case of gastrotoiny for removal of foreign bodies, Richardson, M. 
H., 177, 18;j ; a piece of intestine four and a half inches long with 
six gun-shot wounds, Klliot, J. I)., 183; demonstration of a new 
method of obtaining small quantities of stomach contents for diag- 
nostic purposes, Einhorn, M., 207 ; a caso of gastrostomy, (lay, (i. 
W., 221, 'I'll ; a caso of ruptured intestine, Lewis. II. F.,225; two 
cases of laparotomy for tubercular peritonitis, Wheeler, L., 211 ; 
appendicitis, operation, hernia, recovery, Stedinan, ('. K., 299, 802 ; 
a case of gun-shot wound of important abdominal viscera with re- 
covery, Urio, J. P., 818 ; small tumor of the upper jaw, Kiehardsou, 
M. EC., 325 ; stricture of the (esophagus, its treatment by intuba- 
tion, Mixter, S. J , 320 ; a case 01 obstruction of the bowel, Cash- 
ing, B., 32(i ; malignant stricture of the oesophagus, its treatment 
by Symond's method of permanent tubage, with cases, Mixter, S. 
J., 385 ; infectious dyspepsia and its treatment by the antiseptic 
method, 417; cases of penetrating stab-wounds of the abdomen, 
laparotomy, results, Dalton, II . C, 419 ; case of sarcoma of the ton- 
sil removed by external incision, recovery, Houians, J., 433 ; ap- 
pendicitis, operation, (Jareeau, E., 438 ; a report of my recent ex- 
perience in restoring lacerations involving the sphincter ani by the 
flap-splitting method, Hanks, II. T., 443; inguinal colotomy, Dixon, 

A. , 44(! ; the surgical treatment of tubercular peritonitis, 453 ; 
stomach washing in very young children, 453 ; faucial and pharyn- 
geal tenesmus, ISrowne, lj., 477 ; inflammation in and about the 
head of the colon, McMurty, L. S., 544; surgical treatment of 
appendicitis, 549; appendicitis, (lay, G. W., 557; appendicitis, 
typhlitis and perityphlitis in children, Smith, J. L., 564; surgery of 
the gall-bladder, Ricketts, E., 56!); rectal medication, Caldwell, 
W. H., 57(1; an unsuccessful case of digital dilatation of tbe pylorus 
for cicatricial stenosis, Cutler, K. ( 1., and Richardson, M. H., 581, 
592; perforating gastric ulcer, circumscribed peritonitis, death on 
the fifteenth day, Fitz, R. H., 583, 093; two cases of relapsing ap- 
pendicitis, operation between attacks, removal of appendix, recov- 
ery, Porter, C. B., 611. 

Diphtheria. The recent epidemic of diphtheria in Keene, Faulk- 
ner, H. K., 158; how diphtheria is spread by corpses, Chancellor, 
C. W., 166; erysipelas as a cure for diphtheria, Babiusky, 453; in- 
oculation for diphtheria and tetanus, 575. 

Dislocation. Old anterior dislocation of the humerus, Cabot, A. 
T., 252. 

Dispensary, Boston, 356. 

Diiiretin. Some new clinical experiments with diuretiu, 426. 
Dixon, A. Inguinal colotomy, 446. 

Doctor. Country doctor, 43; doctor and druggist, 304; road-help for 

the country doctor, Potter, 551. 
Dolus, T. M. M. Pasteur and hydrophobia, 117. 
Donhoff, E. von. The management of fractured limbs, 541. 
Drugs. Food, drugs and their adulterations, Daveuport, B. F., 180; 

changes in the tariff on drugs, 476. 
Dudley, A. 1*. Drainage after laparotomy, 422; new method of 

treatment for retro-displacements of the uterus, with adhesions, 

468. 

Dufour. Mumps and inflammation of the lachrymal gland, 357. 
Duhring, L. A. Remarks on the treatment of dermatitis herpeti- 
formis, 251. 

Dwight, T. The scope and the teaching of human anatomy, 83Z; 
recent progress in anatomy, 391; the claim that the merit of intr™ 
ducing ether belongs to the late Dr. Henry J. Bigelow, 553. 

Dyspepsia. Infectious dyspepsia and its treatment by the anti- 
septic method, Woodbury, F., 417. 

Ear. Mastoid sclerosis as illustrated by a typical and fatal case, 
Richards, H., 110; a case in which a septum closely resembling the 
tympanum membrane formed in the middle third of the external 
auditory caual, and was removed with improvement to hearing, 
Theobald, S., Ill; on the renewed employment of the nasal douche 
and kindred procedures. Buck, A. H., Ill; the removal of a bullet 
from the ear with the assistance of the galvano-cautery, Howe, L., 
Ill; permanently good results of excision of the malleus and mem- 
brana tympani, in a case of chronic tinnitus and aural vertigo, and 
in a case of chronic suppuration of the attic due to necrosis of the 
malleus, Burnett, C. H., 112; the Shrapnell perforation, Randall, 

B. A., 112; mastoiditis interna purulenta following erysipelas, Lip- 
pincott, J. A., 112; some cases of mastoid cell disease with a fistu- 
lous opening which recovered without the use of the drill or chisel, 
Pomeroy, O. D., 112; aneurism first recognized in the fundus of the 
ear, later appearing in the neck, Todd, C. A., 112; Dr. Blake's paper 
disk, case histories, Barclay, R., 113; adenoid growths in the naso- 
pharynx, result of their removal in seventy cases of middle-ear 
disease. Jack, F. L., 297. 301. 

K (■/.<■ in a from the use of creolin, 309. 

Editorials. Recent speculations as to the nature of cancer, the 
electrolytic treatment of cancer, 18; a word to young practitioners 
on "changing doctors," 19; the country doctor, 43; the surgical 
fourth, 44; recent views as to inflammation, 67; coats or shirt- 
sleeves? 68; cardiac dyspnoea. 91; the control of syphilis, 115; the 
insanity of cardiac disease, 115; the popular science of economic 
dietetics, 139; national measures for the prevention of food adul- 
teration, 139; the Grand Army meeting, 164; the recognition of eye- 
strain by the general practitioner, 165; the diet of hot weather, 187; 
the Berlin Congress, 188; the Quincy disaster, 188; the functions of 
State boards of health, 208; chemical adulterations of the gastric 
juice in acute and chronic maladies, 209; the present state of bac- 
teriology, 231; the physical symmetry competition at Cambridge, 
257; antisepsis and asepsis in surgery, 258; post-graduate study in 
England, 279; on the treatment of anaemia, 280; doctor and drug- 
gist, 304; the decollete in medical practice, 305; the significance of 
fever, 329, 401 ; old physicians of Hartford, 353; the regulation of 
the practice of medicine in New Jersey, 354; the pathology of in- 
flammation, 377; a plea for conservatism in minor gynecology, 379: 
oxaluria and nervous states, 403; the responsibilities and legal dan- 
gers of cottage hospitals, 425; some new clinical experiments with 
diuretin, 426; beri beri on fishing vessels from the Grand Banks, 
427; index catalogue (volume XI) of the library of the surgeon- 
general's office, 449; autopsies in America, 449; obituary, Henry 
Jacob Bigelow, M.D.,450; the relative value of pharmaceutical and 
hygienic therapeutics, 473; Koch's cure for consumption, 476; Koch's 
treatment for tuberculosis, 497, 574, 598; the pathology of the blood, 
498; the medical examiner vs. the coroner, 500; the Massachusetts 



health report, 547; mortality vs. immortality, 547; physical training 
In the Boston public schools, 548; surgical treatment of appendi- 
citis, 548; an army surgeon's tour of duty with State troops, 574; 
inoculation for diphtheria and tetanus, 575; etiology and treatment 
of epilepsy, 596; report on recent progress in medicine, 598; annus 
medicus MDCCCXC, 622. 

Education. Post-graduate study in Kngland, 279. 

Einhorn, M. Demonstration of a new method of obtaining small 
quantities of stomach contents for diagnostic purposes, 207. 

Electricity. The true position of electricity as a therapeutic agent 
in medicine. Prince, M., 313; electricity for rheumat ism, Walton, 
G. L., 382; discussion on the question of amperage in the treatment 
of fibroid tumors by electricity, 397 ; the electric light as an anal- 
gesic. Von Stein, 453. 

Elliot, J. D. A piece of intestine four and a half inches long with 
six gun-shot wounds, 183. 

Empyema. The surgical treatment of empyema, Goggans, J. A., 
57u. 

Endocarditis. A case of malignant endocarditis secondary to coli- 
tis, remarks, Shattuek, F. C.,79,84: malignant endocarditis, death, 
autopsy, Steam an, C. E., 82, 84. 

England. Post graduate study in England, 279. 

Engelmann, G. J. The causes of ill health in American girls and 
the importance of female hygiene. 545. 

Enuresis. Atropia in the treatment of enuresis. James, J. B., 261. 

Epilepsy. The indications for trephining in epilepsy, Minor, J. C, 
593; etiology and treatment of epilepsy, 596. 

Erichscn's disease as a form of the traumatic neuroses, Clevenger, 
S. V., 217. 

Ernst, H. C. Rabies, 368. 

Erysipelas. The treatment of erysipelas, Allen, C. W., 255; treat- 
ment of erysipelas, 501; facial erysipelas, 551. 

Ether. Ether intoxication, 358; the claim that the merit of intro- 
ducing ether belongs to the late Dr. Henry J. Bigelow, Dwight, 
T., 553; Dr. Bigelow and the introduction of ether, Pineo, P., 554. 

Everett, W. S. A gynecological case, 31. 

Experiments. The responsibility of the physician for experiments 
upon patients even with the latter's consent, 283. 

Extra-uterine pregnancy. Diagnosis, pathology and treatment 
of extra-uterine pregnancy, Johnstone, A. W., 350 ; a esse of rup- 
tured tubal pregnancy, Jewett, C, 351; ectopic pregnancy, Baldy, 
J. M., 351; ectopic pregnancy, Kelly, H. A., 375; two eases of tubal 
pregnancy, Walker, E., 447; indications for operation in ectopic 
pregnancy, Reed, C. A. L., 545. 

Eye. Pons lesions in their relations to associated eye movement 
paralysis, Spitzka, 89; brain tumor with interesting eye symptoms, 
Norris, W. F., 135; history of a case of intracranial neoplasm, with 
localizing eye-symptoms, position of tumor verified at autopsy, 
Oliver, C. A., 135; transient amblyopia with bi'temporal hemianop- 
sia in a case of malarial cachexia, Harlan, G. C, 136; the extraction 
of dislocated lenses from the eye, whether transparent or catarac- 
tous, Bull, C S., 136; some further considerations on the "simple 
operation " for the extraction of cataract. Bull, C. S., 136; removal 
of a large exostosis of the orbit with preservation of the eye, 
Pooley, T. R., 136; operation for ectropion of the lower lid by the 
sliding flap method, Pooley, T. R., 136; case of a foreign body re- 
maining in the eye about twenty years, followed by abscess in the 
scleral wall, opened and recovery, Milliken, B. I.., 136; foreign body 
in the orbit, Norris, W. F., 137; complete paralysis of the lateral 
movements of both eyes, ability to converge remaining intact, Mil- 
liken, B. L., 137; the winking test, Rider, C. E., 137; new tests for 
binocular vision, Lippincott, J. A., 137; can hypermetropia be 
healthfully outgrown? Randall, B. A., 137; treatment of muscular 
asthenopia and its results, Noyes, 11. D., 138; legislation for the 
prevention of blindness, Howe, L., 159; purulent ophthalmia, An- 
drews, J. A., 159; cystlike bodies of the conjunctiva, Andrews, J. 
A., 159; a form of xerosis, Kollock, C. W., 160; two cases of glau- 
coma, Kollock, C. W., 160; embolism of the upper branch of the 
retinal artery, with normal vision, Mittendorf, F. W., 160; a case of 
recurrent irido-choroido retinitis, Theobald, S., 160; a contribution 
to ocular tumors, Carmalt, W. H., 160; progressive astigmatism, 
Jackson, E., 160; three noteworthy cases of ametropia, Theobald, 
S., 160; an analysis of the ocular symptoms found in the third stage 
of general paralysis of the insano, Oliver, C. A.. 161; a new opera- 
tion for symblepharon, Harlan, G. C, 161; cyst of the iris following 
a penetrating wound at tbe corneal margin which caused sympa- 
thetic neuro-retinitis, Risley, S. D., and Randall, B. A., 161; throm- 
bosis of the arteria centralis, central vision unaffected, Wadsworth, 
O. F., 161 ; the recognition of eye-strain by the- general practitioner, 
165; diseases of the eye associated with spinal caries, Young, J., 
327; the insufficiency of the ocular muscles, Wadsworth, O. F., 349; 
report of fifty cataract extractions by a new method, Chandler, H. 
B ,365; a case of metastatic carcinoma of the choroid, W T adsworth, 
O. F., 489; the therapeutics of exophthalmic goitre. Ferguson, E. 
D., 520; recent progress in ophthalmology, Standish, M., 533; throm- 
bosis of arteria centralis retina 1 , large retino-Clliary artery, central 
vision unimpaired, Wadsworth, O. F., 559. 

Farlow, ,J. W. Eight cases of large, pulsating arteries on the pos- 
terior wall of tbe pharynx, 6. 

Faulkner, H . K. The recent epidemic of diphtheria in Keene, 158. 

Ferguson, E. D. The therapeutics of exophthalmic goitre, 520. 

Fever. The significance of fever, 329, 401. 

Fisher, C. I. The necessity , for social and statute recognition of 

syphilis, 101, 106. 
Fisher, E. D. Cerebral compression, 573. 
Fitch, C. W. A true hermaphrodite, 577. 

Fitz, K. H. Henry Jacob Bigelow, M.D., 511: perforating gastric 
ulcer, circumscribed peritonitis, death on the fifteenth day, 583, 593. 

Folsom, C. F. Disorders of sleep, insomnia, 2, 29; a caso of hydro- 
phobia, 367. 

Food. The popular science of economic dietetics, 139; national 
measures for the prevention of food adulteration, 139; bill to pre- 
vent food adulteration, 141; food, drugs and their adulterations, 
Davenport, B. F., 180; the diet of hot weather, 187. 

Ford. \V. C. Question of amperage in the treatment of fibroid 
tumors by electricity, 377. 

Fordyce, .1. A. Peripheral neuritis of syphilitic origin, 39. 

Forster, E. J. Cases of epithelial cancer in a negress, 58; mush- 



viii 



INDEX TO VOLUME OXXIII. 



rooms and mushroom-poisoning, 267; the study of mushrooms, 334; 
the agaricus rodmani not a poisonous mushroom, 454. 
Fourth of July. The surgical Fourth, 44. 

Fractures. Guiles' fracture with especial reference to treatment, 
Huse. It C, 77; the management of fractured limbs, von Dbuhoff, 
E., 541. 

Frankel. Hypnal, 551. 

Freer, A. Infrequency of syphilis in English country practice, 234. 
French, J. M. Consumption in Massachusetts, 340. 
Froitzky. Stomach washing in very young children, 453. 
Frost, C. P. Ptomaines, 157. 

Furunculi. The treatment of furunculosis, Hofrat, 578. 

Gall-bladder. Surgery of the gall-bladder, Ricketts, £., 569. 

Gangrene. The local and general treatment of gangrenous wounds 
and diseases, 545. 

Garceau, K. Appendicitis, operation, 438. 

Gastrostomy. A case of gastrostomy, Gay, G. W., 221, 227. 

Gay, G. \V. A case of gastrostomy, 221, 227; appendicitis, 557. 

Generative System. A gynecological case, Everett, W. S., 31; 
hyaline-fibroid ovarian disease, Gibbes, II., 127; report of progress 
in gynecology, Davenport, F. H., 153; unilocular papillomatous 
cyst of the left ovary, Russell, W., 150; ninety cases of dysmenor- 
rhea and sterility treated by rapid dilatation of the cervical canal, 
Townsend, 166; ovarian hernia?, their causes, symptoms and treat- 
ment. Madden, T. M., 190; a case of vaginal hysterectomy, Daven- 
port. F. H., 200, 202; a case of calcareous fibro-myomaof the uterus, 
Ingalls, W., 201, 204; a case of vaginal hysterectomy for cancer, re- 
covery, 201, 202; question of amperage in the treatment of fibroid 
tumors by electricity, Ford, W. C., 377; dermoid cyst of the ovary, 
Cabot, A. T.,278; treatment of uterine tibro-myoniata by abdominal 
hysterectomy, Irish, J. C, 293; a plea for conservatism in minor 
gynecology, 379; discussion on the question of amperage in the 
treatment of fibroid tumors by electricity, 397; vaginal fixation of 
the stump in abdominal hysterectomy, Byford, H. '1'., 398; mechan- 
ical obstruction in diseases of the uterus, Hulbert, G., 418; is the 
mortality after gynecological operations affected by climatic influ- 
ences? Coe, H. C.,421; drainage after laparotomy, Ashby, T. A., 
422; drainage after laparotomy, Dudley, A. P., 422; two cases of 
hydatidiform mole, Chadwick, J. R., 423; a report of my recent ex- 
perience in restoring lacerations involving the sphincter ani,by the 
flap-splitting method, Hanks, H. T., 443; new method of treatment 
for retro displacements of the uterus, with adhe.- ions, Dudley, A. 
P., 46K; sterility 477; how shall we treat our cases Of pelvic inflam- 
mation ? Maury, R. 15., 543; uterine moles and their treatment, 
Wilson, J. T., 568; a review of the treatment of varicocele, Lydston, 
G. F., 569; hydrocele in children, with a report of cases, Lovett, R. 
W., 584, 592. 

Gibbes, H. Hyaline-fibroid ovarian disease, 129; is the unity of 

phthisis an established fact? an important consideration in regard 

to the cure of the disease by inoculation, 608. 
Gibbes, If., and Shurly, E. L. Tubercle bacilli, 487. 
Gibier, P. Sensations produced by the anti-hydrophobic Pasteur 

inoculations, as described by inoculated subjects, 184. 
Girls. The causes of ill health in American girls and the importance 

of female hygiene, Engelmann, G. J., 545. 
Gluck, T. Antiseptic cement for promoting bony union, 235. * 
Goggans, J. A. The surgical treatment of empyema, 570. 
Gonorrhoea. Some points in the treatment of gonorrhoea, Allen, G. 

W., 121, 132; treatment of gonorrhoea, 552. 
Gouley, J. W. S. Retention of urine from prostatic obstruction in 

elderly men, its nature, diagnosis and treatment, 471. 
Graham, II. Paraffo-stearine, a substitute fur starch, plaster-of- 

Paris, and such materials, for bandages and splints, 602. 
Graham, J., and I lubbe, C. P. B. A case of hydatid tumor of the 

braiu, removal, recovery, 284. 
Grand army meeting, 164. 
Gray, L. C. Astasia and abasia, 570. 

Green, C. M. The influenza epidemic as observed at the Boston 

Lying-in Hospital, 55, 59; report on obstetrics, 130. 
Groenouw. Acute oedema glottidis after potassium iodide, 21. 
flaeckel. Phosphorus necrosis, 500. 

Haemophilia. A case of haemophilia as observed at the first men- 
strual period, Townsend, C. W., 516, 525; menorrhagia in a patient 
afflicted with hiemophilia, Vickery, H. F., 520, 525; a case of haem- 
ophilia as observed at the first menstrual period, Tiukham, G. W., 
525. 

Hall, J. N. A case of homicide in which the location of the powder- 
brand assisted in establishing the innocence of the accused, 152. 

Haller, J. F Modern physical deterioration and some remedial 
suggestions, 391. 

Hammond, G. M. The pathological findings in Dr. W. A. Ham- 
mond's case of athetosis, 63. 

Hanks, H. T. A report of my recent experience in restoring lacer- 
ations involving the sphincter ani by the Hap splitting operation, 
443. 

Harlan, G. O. Transient amblyopia with bi temporal hemianopsia 
in a case of malarial cachexia, 136; a new operation for symble- 
pharon, 161. 

Harriman. A. H. Combined intra and extra twin pregnancy, 156. 
Harrington, A. H. Epidemic influenza and insanity, 126. 
Harrington, F. B. The value of " primary amesthesia" in minor 

surgical operations, 434, 411. 
Hartford. Old physicians of Hartford, 353. 
Heart failure, Whittier, E. N., 222. 227. 

Help and hindrance to medical progress, Hollister, J. H., 418. 
Hermaphrodite. A true hermaphrodite, Fitch, C. W., 577. 
Heuter. A contribution to the pathology of the solitary tubercle of 

the spinal cord, 89 
Miland, T. Medical men, 158. 
Hills, W. B. Report on medical chemistry, 6. 

Hip. A case of compound dislocation of the hip, with recovery, 

Perkins, .1. W., 362. 
Hofrat. The treatment of furunculosis. 578. 

II. .1.1. -ii K. Wire-loop euretto for removing new adenoid growth 
from the pharynx, 12. 

Hollister, J. II. Help and hindrance to medical progress, 418. 

Holt, I.. K., and VanGieson, I. Case of spina bifida with suppur- 
ative meningitis and ependymitis of bacterial origin, 572. 



Homans, J. A case of vaginal hysterectomy for cancer, recovery, 
201, 2u2; case of sarcoma of the tonsil, removed by external inci- 
sion, recovery, 433. 

Homans, J., 2nd. Observations on a case of perityphlitis, 81, 84. 

Hooper, F. H. Report on laryngology and rhinology, 413. 

Hospitals. The Boston City Hospital, 15 lake, C. J..1; the New 
York Floating Hospital, 211; Boston Children's Hospital, 600. 

Howe, li. The removal of a bullet from the ear with the assistance 
of the galvano-cautery, 111; legislation for the prevention of blind- 
ness, 159. 

Hulbert, G. Mechanical obstruction in diseases of the uterus, 418. 
Huse, K. C. Colles' fracture, with especial reference to treatment, 
77. 

Hydrophobia. M. Pasteur and hydrophobia, Dolan, T. M., 117; 
sensations produced by the anti-hydrophobic Pasteur inoculations, 
as described by inoculated subjects, Gibier, P., 184; a case of hydro- 
phobia, Folsoin, C. F.. 367; rabies, Ernst, H. C.,368; a hydrophobia 
scare, Spring, C. W., 3X8; discussion on rabies or hydrophobia, 396. 

Hygiene, Health and Boards of Health. The Berlin water and 
sewage works, Virchow, B.,189: the functions of State boards of 
health, 20S; Colorado as a health resort, Atkins, E C.,390; interna- 
tional congress of hygiene and demography, 454; hygiene in the 
public schools, Chapin, H. S., 472; the relative value of pharmaceu- 
tical and hygienic therapeutics, 473. 

Hypnotism. Some conservative views of hypnotism, 21; a grand 
exhibition of hypnotism, 46; blistering by hypnotic suggestion, 
Rybalkin, I. V., 333; hypnotism in its relation to surgery, Lain- 
phear, E., 446; hypnotism, Schmid, E., 470. 

Hysteria. Some extra-medical manifestations of hysteria, With- 
ington, C. F., 193. 

Immigrants. Medical inspection of immigrants by consular physi- 
cians, 71. 

India. Early marriages in India, 357. 

Inflammation. Recent views as to inflammation, 67; .the pathology 
of inflammation, 377. 

Influenza. Influenza in Massachusetts, Sbattuck, G. B., 25, 49. 73, 
97; the influenza epidemic as observed at the Boston Lying-in Hos- 
pital, Green, C. M.,55.59; epidemic influenza and insanity, Har- 
rington, A. H., I26; influenza in the out-patient department of the 
Boston City Hospital, Buckingham, C. E., 343, 348. 

Ingals, E. F. Supplemental report on cartilaginous tumors of the 
larynx and warty growths in the nose, 35; unilateral paralysis of 
the lateral crico arytenoid muscle, 36. 

Ingalls, W. A case of calcareous nbro-mvoma of the uterus, 201, 
204. 

Inheritance of disease, 159. 

Insomnia. Disorders of sleep, insomnia, Folsom, C. F., 2, 29. 

Inst uments and Apparatus. An instrument for removing glan- 
dular hypertrophies from the tongue, Roe, J. O., 12; wire-loop 
curette for removing adenoid new growth from the pharynx, 
Holden, E., 12; the ausculatory percussor. Seaman, L. L., 63; evac- 
uators for litholapaxy, Newell, O. K., 133; another needle forceps, 
Burrage, W. L., 274; anew bed for use in hip disease, Pheips, A. 
M., 274; a simple female catheter, Knstner, O., 452; Professor 
Koch's subcutaneous syringe, 550; paraffo-stearine, a substitute 
for starch, plaster-of- Paris, and such materials, for bandages and 
splints, Graham, H., 602. 

Internati nal congress of hygiene and demography, 454. 

Irish, J. C. Treatment of uterine flbro-myomata by abdominal 
hysterectomy, 293; double primary and actually synchronous am- 
putation of the lower extremities, with recovery, 616. 

Irwin, F. A large surgical cyst of the kidney, 278. 

Italy. Letter from Italy, 502, 552. 

Jack, F. L. Adenoid growths in the naso-pharynx, result of their 
removal in seventy cases of middle ear disease. 297 , 301. 

Jackson, E. A case of progressive astigmatism, 160. 

Jac kson, G. T. Electrolysis in the treatment of lupus vulgaris, 255. 

James, J. B. Atropia in the treatment of enuresis, 261. 

Jaw. Small tumor of the upper jaw, Richardson, M. H., 325. 

Jewett, C. A case of ruptured tubal pregnancy , 351 ; the compara- 
tive value of biniodide and bichloride of mercury as surgical anti- 
septics, 443. 

Johnstone, A. W. Diagnosis, pathology and treatment of extra 
uterine pregnancy, 350. 

Joints. High temperature in chronic joint disease, Lovett, R. W., 
135; rheumatic arthritis of knee, Ketch, S., 275; suppurative in- 
flammation of the knee-joint treated by drainage through the 
popliteal space, Richardson, M. II., 277. 

Judson, A. B. Hematoma of the sterno-cleido mastoid muscle, 274; 
ankle-joint disease, 617. 

Jurisprudence. A case of homicide in which the location of the 
powder brand assisted in establishing the innocence of the accustd. 
Hall, J. N., 152; two medico-legal decisions, 283. 

Karewski. The diagnosis and treatment of cysts of the pancreas, 
600. 

Kelly, H. A. Continuation of the discussion on ectopic pregnancy, 

375; cephalhematoma, 421. 
Ketch, S. Rheumatic arthritis of knee, 275; posterior rachitic 

curvature of the spine, 328. 
King, VV. P. Wiring the separated symphisis pubis, supplemented 

by a novel pelvic clamp, 446. 
Kisch, H. Treatment of obesity, 235. 
Klotz, H. G. Notes on pilocarpine in dermatology, 255. 
Knee. Excision of the knee fur angular anchylosis, report of four 

cases, Lovett, R. W., 178. 
Knight, C. H. Case of libro-sarcoma of the right nasal fossa, with 

unusual clinical history. 34. 
Knoff. Pericarditis in childhood, 380. 

Koch. Koch's cure for consuniuti D, 476; Koch's treatment for 
tuberculosis, 497, 574, 59*; Professor Koch's subcutaneous syringe, 
5/,0; Koch's lymph, 550; inoculations for pulmonary tuberculosis, 
Roldt, U. J.. 567. 

Kollock, C. W. A form of xerosis, 160; two cases of glaucoma, 160. 
Kunkel. Decomposition of chloroform by artificial light, 453. 
K ust ner, O. a simple female catheter, 452. 
l.amphfar, E. Hypnotism in its relation to surgery, 446. 
Langdon, W. V. Tenotomy to increase the mobility and power of 
the musician's linger, 118. 



INDEX TO VOLUME OXX1II. 



IX 



Langmaid, S. W. Hoarseness and loss of voice caused by wrong 
vocal method, 36. 

Laparotomy. Two cases of laparotomy for tubercular peritonitis. 
Wheeler, L., 241; drainage after laparotomy, Ashby, T. A., 422; 
drainage alter laparotomy, Dudley, A. P., 122; laparotomy for 
ilitra-pclvic pain, &Bhby, T, A., 444; laparotomy under cocaine, .Mil. 

Larynx. Report on laryngology and rbinology, Hooper, V. II., 413. 

Law, (}. K. 'J'he treatment 01 pseudo membranous laryngitiH by 
mercurial fumigation, 235. 

Leo, IS. The nervous and muscular elements in the causation of 
idiopathic curvature, 327. 

Leprosy- A case of leprosy, McCollom, J. H., 350; leprosy in Vene- 
zuela. 452. 

Lewis, II. F. A case of ruptured intestine, 225. 
Libel. A two bundled thousand dollar libel suit, 282. 
Lichen. Clinical notes on lichen planus, Bulklcy, L. D., 495. 
Lipplneott, J. A. Mastoiditis interna purulenta following erysipe- 
las, 112; new tests for binocular vision, 137. 
Litholapaxy. Kvaeuators for litholapaxy, Newell, O. K., 133. 
Liver. Cancerous liver, Siednian, C. E., 325. 
Love, I. N. Coffee, 41*. 

Lovett, It. YV. Excision of the knee for angular anchylosis, report 
of four cases, 178; higb temperature in chronic joint disease, 135; 
the treatment of cold abscesses without drainage, with report of 
cases, 272; the etiology of lateral curvature, 327 ; lateral deviation 
of the spinal column in Pot t's disease, 32*. 345; acute circumscribed 
oedema, Kill; hydrocele in children, with a report of cases, 584, 592. 

Lydston, G. F. A review of the treatment of varicocele, 569. 

Lyman, G. H. Some aspects of our medical service in the War of 
the Rebellion, 145, 169. 

MacCoy, A. W. A case of fibro-niyxomatous tumor taken from the 
naso pharynx of a child six years of age, 13. 

Mackenzie, J. N. Annual address before the American Laryn- 
ttplogical Association, 10; a suggestion concerning the intimate 
relationship between bulbo-nuclear disease and certain obscure 
neurotic conditions of the upper air-passages, 10. 

Mackenzie, S. African sleeping sickness, 601. 

Madden, T. M. Ovarian hernias, their causes, symptoms and treat- 
ment, 190; the treatment of cystitis in women, 211. 

Mauley, T. H. Cocaine analgesia, its extended application in gen- 
eral surgery, when hypodermically employed, 458. 

Materia Medica and Therapeutics. Recent speculations as to 
the nature of cancer, the electrolytic treatment of cancer, 18; 
iodide of sodium and iodide of potassium, Coggin, D., 47; cases of 
cystitis treated with salol, Abbot, S. L.,57; remarks on therapeu- 
tics as applied to nervous disorders, Birdsall, W. R.,91; antiseptics 
and anaisthetics at Berlin, 234; the treatment of pseudo-niem- 
branous laryngitis by mercurial fumigation, Law, G. E., 235; anti- 
septic cement for promoting bony union, 235; electrolysis in the 
treatment of lupus vulgaris, Jackson, G. T., 255; aristol, Allen, C. 
W., 255; notes on pilocarpine in dermatology, Klotz, H. G.,2.55; the 
treatment of derniatologtcal cases by sulphur water at Richfield 
Springs, Ransom, C. C. 255; antisepsis and asepsis in surgery, 258; 
atropia in the treatment of enuresis, James, J. B., 261; the true 
position of electricity as a therapeutic agent in medicine. Prince, 
M., 313; antiseptics and ether, Coggin, D.. 358; electricity for rheu- 
matism, Walton, G. L., 382; chlorate of potassium as a preventive 
of intra-uterine death, Chadwick, J. R., 424; some new clinical ex- 
periments with diuretin, 426; the comparative value of biniodide 
and bichloride of mercury as surgical antiseptics, Jewett, C, 443; 
the hypodermic use of arsenic, Moyer, H. N., 447; cocaine analge- 
sia, its extended application in general surgery, when hypoder- 
mically employed, Mauley, T. H., 458; calomel plaster for syphilis, 
Quinquand, 476; stryebniue as an antitetanus vaccine, Peyraud. 
478; the continuous inhalation of oxygen in pneumonia otherwise 
fatal, and in other diseases, Blodgett, A. N., 481, 493; report on pro- 
gress in therapeutics, Williams, F. H., 490, 518; Hypnal, Frankel, 
551; wet antiseptic dressings in injuries of the hand, Nicolson, W. 
P., 56s; silicate of soda, some new methods of use in surgery, Bax- 
ter, G. A., 569; peroxide of hydrogen, 579. 

Maury, K. B. How shall we treat our cases of pelvic inflammation? 
543. 

McCollom, J. H. A case of leprosy, 350. 

McKinley bill. Changes in the tariff on drugs, 476. 

McMuity, L. S. The application of antiseptic methods in mid- 
wifery practice, 448; inflammation in and about the head of the 
colon, 544. 

Medical examiner vs. the coroner, 500. 

Medical men, Hiland, T., 158. 

Medical register for New England, 577. 

Microscopy. Hardening of sections of the spinal cord by electricity, 
Minor, 476. 

Milliken, B. L. Case of a foreign body remaining in the eye about 
twenty years, followed by abscess in the scleral wall, opened and 
recovery, 136; complete paralysis of the lateral movements of both 
eyes, ability to converge remaining intact, 137. 

"Min. The insanity of cardiac disease, 115; epidemic influenza and 
insanity, Harrington, A. H., 126; an analysis of the ocular symp- 
toms found in the third stage of general paralysis of the insane, 
Oliver, C. A., 161; the care of the insane in local institutions, Moul- 
ton, A. B., lUt;. 

Minor. Hardening of sections of the spinal cord by electricity, 476. 
Minor, ,J. C. The indications for trephining in epilepsy, 593. 
Minot, C. S. On the fate of the human decidua reflexa, 561. 
Minot, F. Sudden death probably from oedema of the glottis, 536, 
540. 

Mitchell, S. W. Double consciousness, 42. 

Mitchell, S. \V., and Burr, C. W. Unusual forms of chorea, pos- 
sibly of spinal origin, 41. 

Mittendorf, F. XV. Embolism of the upper branch of the retinal 
artery, with normal vision, 160. 

Mixter, S. J. Stricture of the oesophagus, its treatment by intuba- 
tion, 326; malignant stricture of the oesopbagu-, its treatment by 
Symond's method of permanent tubage, with cases, 385, 

Mollenhauer, R. On the germ of a communicable disease derived 
from a dog, alleged to have died of rabies, which retains tabic char- 
acters, 90. 

Monks, G. H. A new method for the treatment of injuries to the 



shoulder, 183; a case of enlarged subcutaneous bursa in front of 
the tubercle of the tibia, 591, 592; enormouB hypertrophy of the 
nose, 592. 

Morris, \V. F. Brain tumor, with interesting e\e symptoms, | 
Morrow, I*. A. Address before the American Oermalological As- 
sociation, 252. 
Mortality vs. Immortality, 547. 

Morton, T. G. Method of dealing with club-foot, 327. 

Moulton, A. K. The care of the insane in local institutions. 

Moyer, II. N. The hypodermic use ol arsenic, 447. 

M add, II. G. Fibro-niyoma of the male pelvis, 16. 

Mumps. Mumps and inflammation of the lachrymal gland, Dulour, 

357; mumps, liordas, 477. 
Mnrdock, K. Torsion of arteries as a means for the arrest of hajm- 

orrhage, 420. 

Muscular System* Diffuse calcification of the muscular system in 
a case of fracture, Chase, W. 1)., 158. 

Mushrooms and mushroom-poisoning, Forsti-r, 10. J., 267; the study 
of mushrooms, Forster, 1*:. J., 334; the agarieus rodmani not a poi- 
sonous mushroom, Forster, E. J., 454; the study of mushrooms, 
Palmer, J. A., Jr., 554. 

Musician. Tenotomy to increase the mobility and power of the 
musician's linger, I.angdon, F. W., 118. 

Myers, T. H. The prognosis of pressure paralysis, 328; the treat- 
ment of ankle-joint and tarsal disease, 617. 

Nervous System. Unilateral paralysis of the erico-arytenoid mus- 
cle, lugals, E. F., 36; a case of unilateral paralysis of the larynx, 
the result of an attack of bulbar disease, With unusual symptoms, 
Bos worth, F., 36; peripheral neuritis of syphilitic origin, rordyce, 
J. A., 39; unusual tonus of chorea, possibly of spinal origin, 
Mitchell, S. W., and Burr, C. H.. 41 ; double consciousness, Mitchell, 
S. W., 42; chronic softening of the cord, senile paraplegia, Dana, 
C. L., 42; a case in which cerebral localization was illustrated by 
the effect of mental impression, Smith, A. 11., 45; traumatic neuro- 
psychoses, Walton, G. L., 60; a case of complete paraplegia cured 
by trephining, Dercum, F. X., 61; a case of locomotor atax.a asso- 
ciated with nuclear cranial palsies, and with muscular atrophies, 
Peterson, F., 61; multiple neuritis, or beri-beri, among seamen, 
Putnam, J. J., 62; on cases of postero-lateral sclerosis, with special 
reference to the pathology of the disease, Putnam, J. J., 62; the 
pathological findings in Dr. W. A. Hammond's case ot athetosis, 
Hammond, G. M., 63; on ingravescent apoplexy, Dana, C. L , 88; 
pons lesions in their relations to associated ej e movement pai alysis, 
Spitzka. 89; a contribution K/ the pathology of the solitary tubercle 
of the spinal cord, Heuter, 89; demonstration of some special anat- 
omical characteristics in the bra n of a distinguished scientist, 
Wilder, 15. J., 89; tumor ot the quailrigeminal region with special 
reference to ocular symptoms, Sachs, B., 89; crus lesions, Sachs, 
B., 9tl; ou the germ of a communicable disease derived from a dog, 
alleged to have died of rabies, which retains rabic characters, 
Mollenhauer, R., 90; a case of insular sclerosis in which an attack 
of cerebral haemorrhage arrested the tremor on the heiuiplegic side, 
Sinkler, W., 91; remarks on therapeutics as applied to nervous dis- 
orders, Birdsall, W. R., 91; M. Pasteur and hydrophobia, Dolan, T. 
M., 117; brain tumor with interesting eye-symptoms, Morris, W. F., 
135; history of a case of intracranial neoplasm, with localizing eye- 
syniptoms, position of tumor verified at autopsy, Oliver, C. A., 135; 
an analysis of the ocular sj inptoins found in the third stage of gen- 
eral paralysis of the insane, Oliver, C. A., 161; some extra medical 
manifestations of hysteria, Withington, C. F., 193; F.richseu's dis- 
ease as a form of the traumatic neuroses, Clevei.ger, S. V., 217; 
craniectomy for niiciocephalic cretinism, Wenut, E. C., 238; a form 
of polyneuritis, probably analogous to or identical with beri-beri, 
occurring in seafaring men in Northern latitudes, Putnam, J. J., 
244; a case of hydatid tumor of the brain, removal, recovery, Gra- 
ham, J., and Clubbe, C. P. B., 284; a case of congenital lock-jaw, 
Sayre, R. H., 274 ; seizures characterized by shock and sudden coma, 
Dana. 1. T., 289; the treatment of deformities of spastic paralysis, 
Bradford, E. 11., 303; a case of considerable cerebral hamiorthage 
without symptoms, Shattuck, G. B., 324; the prognosis of pressure 
paralysis, Myers, 'I . H., 328; oxaluria and nervous states, 403; fatal 
case of lead poisoning m which ataxia was the principal symptom 
(pseudo tabes), Walton, G. L., 411; a case of multiple neuritis due 
to arsenic. Cutler, E. G., 463, 465; a case of pseudo-muscular hyper- 
trophy in an adult, Culler, E. G., 4i>5; discussions on intra cranial 
lesions, 469; strychnine as an antitetanus vaccine, Peyraud, 478; 
traumatic tetanus, recovery, Tanci), A. XV , 478; the surgical treat- 
ment of spastic paralysis in children, Bradford, E. H.,485; a neuro- 
plastic operation, designed for the restoration of nerve trunks that 
have been destroyed by injury or disease, Beach, H. H. A., 562; 
astasia and abasia, Gray, L. C, 570; syringomyelia '.' Shaw, S. E., 
571; case of spina bifida with suppurative meningitis and ependy- 
mitis of bacterial origin. Holt. L. E., and VanGieson, I., 572; cere- 
bral compression, Fisher, E. D., 573; the indications for trephining 
in epilepsy. Minor, J. C, 593; etiology and treatment of epilepsy, 
596; early diagnosis of some serious diseases of the nervous systtni, 
its importance and feasibility, Seguin, E. C, 605. 

Newell, O. K. Evacuators for litholapaxy, 133; value of cystoscopy 
in the diagnosis of surgical diseases ol the kidney, 591. 

New Jersey. The regulation of the practice of medicine in Ntw 
Jersey, 354. 

Nicolson, W. P. Wet antiseptic dressings in injuries of the hand, 
568. 

Noise. Unnecessary noise an avoidable evil in a city, Buckingham 
E. M., 430. 

Norman, S. Treatment of organic stricture of the male urethra, 
448. 

Norris, W. F. Foreign body in the orbit, 137. 

Nose. Congenital deformity of the nose, Bradford, F. H., 586; enor- 
mous hypertrophy of the nose, Monks, G. H., 592. 

Noyes, H. 1). Treatmeutof muscular asthenopia and its results, 138. 

Obesi'y. Treatment of obesity, Kisch, H., L'3~>. 

Obstetrics. Report on obstetrics, Green, C. M., 130. 

(Edema. Acute circumscribed oedema, Lovett, R. W., 409. 

(Esophagus. Stricture of the oesophagus, its treatment by intu- 
bation. Mixter, S. J., 326; malignant stricture of the oesophagus, 
its treatment by Symonds's method of permanent tubage, with 
cases, Mixter, S. J., 385. 



X 



INDEX TO VOLUME CXXIII. 



Oliver, C. A. History of a case of intracranial neoplasm, with local- 
izing eye-symptoms, position of tumor verified at autopsy, 135; an 
analysis of the ocular symptoms found in the third stage of general 
paralysis of the insane, 161, 

Opium. Breaking the opium habit, Ball, 477. 

Orton, J. G. Address before New York State Medical Association, 
468. 

Orthopraxy. The treatment of lateral curvature, Bradford, E. H., 
250; rachitic posterior curvature of tibise, Townsend, W. K., 275; 
address before the American Orthopedic Association, Willard, DeF., 
303; the treatment of deformities of spastic paralysis, Bradford, E. 
H., 303; amputation as an orthopedic measure, Vance, A. M., 303; 
method Of making counter extension at the knee-joint, Taylor, H. 
L., 304; the nervous and muscular elements in the causation of 
idiopathic curvature, Lee, B., 3^7; the strength of the back mus- 
cles of one thousand one hundred and forty-one of the school-girls 
of Boston, Scudder, C. L.,327; the etioiogy of lateral curvature, 
Lovett, K. W., 327; method of dealing with club-foot, Morton, T. 
01., 327; the treatment of lateral curvature, Bradford, E. H., 327; 
the treatment of lateral curvature, Taylor, H. L.,327; a report of 
sixty-two cases of hip disease observed in the practice of H. 0. 
Thomas of Liverpool, Kidlon, J., 327; diseases ot the eye associated 
with spinal caries, Young, J., 327; posterior rachitic curva ure of 
the spine, Ketch, t>., 328; lateral deviation of the spinal column in 
Pott's disease, Lovett, K. \V., 3-8, 345; a ready method for counter- 
extension of the knee, Taylor, H. L., 3C1; a determination of the 
muscular strength of growing girls and its relation to Ure etiology, 
treatment and prognosis of lateral curvature of the spine, Scudder, 
C. It., 436; report on the recent progress of orthopedic surgery, 
Bradford, E. H., and Lovett, R. VY., 439, 461. 

Orvananos. The federal district in the Kepublic of Mexico, as a 
suitable residence for persons predisposed to tuberculosis, and for 
the relief of pulmonary consumption, 6111. 

Otis, F. N. Removal of the third lobe of the prostate, with complete 
restoration of the functions of the bladder, 15. 

Oxaluria and nervous states, 403. 

Oxygen. The continuous inhalation of oxygen in cases of pneumo- 
nia otherwise fatal, and in other diseases, Blodgett, A. N., 481, 493. 

Palmer, J. A., Jr. The study of mushrooms, 554. 

Pancreas. The diagnosis and treatment of cysts of the pancreas, 
Karewski, 600. 

Pancreatitis. A case of acute pancreatitis, 46. 

Paris. Letters from Paris, 22, 381. 

Pasteur. M. Pasteur and hydrophobia, Dolan, T. M., 117; New 

York Pasteur Institute, 405. 
Pavy, F. W. The treatment of diabetes, 236. 
Peaii, Dr., 22. 

Pelvis. The motive and method of pelvic surgery, Price, J., 543. 

Peritonitis. Two cases of laparotomy for tubercular peritonitis, 
Wheeler, L., 241; the treatment of general septic peritonitis, Robin- 
son, VV. L., 546. 

Perityphlitis. Observations on a case of perityphlitis, Homans, J., 
2nd, 81, 84. 

Perkins, J. W. A case of compound dislocation of the hip, with 

recovery, 362. 
Peroxide of hydrogen, 579. 
Petersen. Curetting the soft chancre, 476. 

Peterson, V. A case of locomotor ataxia associated with nuclear 
cranial nerve palsies, and with muscular atrophies, 61. 

Peyraud. Strychnine as an antitetanic vaccine, 478. 

Pfeif fer, O. J. The medical department of the Union Pacific Rail- 
way, 405. 

Pharmacy. The relative value of pharmaceutical and hygienic 
therapeutics, 473. 

Pharynx. Eight cases of large pulsating arteries on the posterior 
wall of the pharynx, Fal low. J. W., 6; cases of erysipelas of the 
pharynx, Sennander, K. (;., 357. 

Phelps, A. M. A new bed tor use in hip disease, 274. 

Phosphorus necrosis, lheckel, 500. 

Phthisis. Professor Flint's doctrine of the self-limitation of phthi- 
sis, Porter, Vv\, 418; consumption in Massachusetts, Stetson, G. K., 
454; Koch's cure for consumption, 474 ; is the unity of phthisis an 
established fact? an important consideration in regard to the cure 
of the disease, by inoculation, Gibbes, H., (ins. 

Plneo, P. Dr. Bigelow ami the introduction of ether, 554. 

Poisons. Poisoning in the Bombay presidency, 234 ; mushrooms and 
mushroom-poisoning, Porster, E. J., 267, 334; fatal case of lead poi- 
soning in which ataxia was the principal symptom (pseudo-tabes), 
Walton, G. L.,411. 

Pomeroy, O. I). Some cases of mastoid cell disease with a fistulous 
opening which recovered without the use of the drill or chisel, 112. 

Foidcy, T. K. Itemoval of a large exostosis of the orbit with pre- 
servation of the eye, 136; operation for ectropion of the lower lid 
by the sliding-llap method, 136. 

Porter, C. I!. Amputation at the shoulder-joint for sarcoma, 181; 
two cases of relapsing appendicitis, operation between attacks, re- 
moval ot appendix, recovery, 611. 

Porter, \V. Professor Flint's doctrine of the self-limitation of 
phthisis, 418. 

Post, A. A case of coccyodyuia, removal of coccyx, recovery, 300; 
suprapubic lithotomy in a boy of twelve, 393. 

Potter, S. O. ti. A road-help for the country doctor, 551. 

Potter, T. Certainty in the diagnosis of tuberculosis, 446. 

Powers, C. A. Non-union of fractured radius, 616. 

Pregnancy, Affections connected with. A case of greatly pro- 
longed gestation, Wilson. H., 94; report on obstetrics, Green, C. M., 
130; combined intra and extra twin pregnancy, Harriman, A. H., 
156; posthumous labor, 165; some new advice to those who would 
practice antiseptic midwifery, 166; after-treatment of obstetric 
cases, Wood, W. B., 204; diagnosis, pathology and treatment of 
extra-uterine pregnancy, Johnstone, A. W.,350; a case of ruptured 
tubal pregnancy, .Jewett. C, 351 ; ectopic pregnancy, Baldy, J. M., 
351; ectopic pregnancy, Kelly, II. A., 375; early marriages in India, 
367; obstetrical work in a cottage hospital, Colt, H., 386; injuries 
to the ureters during labor, Skene, A. . I. C, 399; two unusual ob- 
stetric eases, Vickery, II. F., 212; treatment of abortions, Baldw in, 
H. C., 423; two cases of tumors coincident with pregnancy, Chad- 
wick, J. R., 424; chlorate of potassium as a preventive of intra- 



uterine death, Chadwick, J. R., 424; pregnancy after the removal 
of both ovaries. Robertson, J. A., 429; measurements of the uterine 
cavity in child-bed, Richardson, W. L., and Sinclair, A. D., 444; 
wiring the separated symphysis pubis, supplemented by a novel 
pelvic clamp. King, W. P., 446; two cases of tubal pregnancy, 
Walker, E.,447; the application of antiseptic methods in midwifery 
practice, McMurtry, L. S., 448; obstetrics, 521; two cases of preg- 
nancy complicated with tumors, Chadwick, J. R., 532; indications 
for treatment in ectopic pregnancy, Reed, C. A. L., 545. 

Price, J. The motive and method of pelvic surgery, 543. 

Prince, M. The true position of electricity as a therapeutic agency 
in medicine, 313. 

Prognostics in medicine, Cronyn, J., 468. 

Prurigo. Observations on prurigo, clinical and pathological, Tay- 
lor, R. W., 253. 

Pruritus. A clinical study of pruritis hemialis, winter itch, frost 
itch, etc., Corlett, W. T., 253; a study on pruritus, Bronson, E. B., 

253. 

Ptomaines, Frost, C. P., 157. 

Pubes. Wiring the separated symphysis pubis, supplemented by a 
novel pelvic clamp, King, W. P., 416. 

Putnam, J. J. Multiple neuritis or beri-beri among seamen, 62; 
on cases of postero-lateral sclerosis, with special reference to the 
pathology of the disease, 62; a form of polyneuritis, probably anal- 
ogous to or identical with beri-beri, occurring in seafaring men in 
Northern latitudes, 244. 

Queen Bess. The reign of good Queen Bess, Richardson, B. W., 308. 

{juiney. The Quincy disaster, 188. 

(juinquand. Calomel plaster for syphilis, 476. 

Railway. Railway hygiene, Conn, G. P., 155; the medical depart- 
ment ot the Union Pacific Railway, Pfeifl'er, O. J., 405. 

Randall, B. A. The Shrapnell perforation, 112; can hypermetropia 
be healthfully outgrown? 137. 

Ransom, C. C. The treatment of dertnatological cases by sulphur 
w ater at Richfield Springs, 255. • 

Rarities. Clinical study of rarities or of common diseases, 282. 

Recent Progress. Report on medical chemistry, Hills, W. B., 6; 
diseases of children. Rotch, T. M., 103, 587, 614; obstetrics, Green, C. 
M., 130; gynecology, Davenport, F. H., 153; food, drugs and their adul- 
terations, Davenport, B. F., 180; surgery, Burrell, H. L., and Cush- 
ing, H. W., 319; anatomy, Dwight, T., 891; laryngology and rhi- 
nology. Hooper. F. H., 413; orthopedic surgery, Bradtord, E. H., 
and Lovett, K. W., 439, 461; therapeutics, Williams, F. H., 490, 516; 
ophthalmology, Standish, M., 533; report on progress in derma- 
tology, Bowen, J. T., 562, 589; report on recent progress in medi- 
cine, 598. 

Reed, C. A. I>. Indications for operation in ectopic gestation, 
545. 

Respiratory System. A suggestion concerning the intimate rela- 
tionship between bulbo-nuclear disease and certain obscure neu- 
rotic conditions of the upper air-passages .Mackenzie, J. N., 10; 
look beyond the nose, Cohen, S. S., 11; au instrument for removing 
glandular hypertrophies from the tongue, Roe, J. <>., 12; wire-loop 
curette for removing adenoid new growth from the pharynx, Hol- 
den, E., 12; a new operation for removing adenoid new growth from 
the pharynx, Asch, M. J., 12; a case of fibro-myxomatous tumor 
taken from the naso pharynx of a child six years of age, Mactoy, 
A. W., 13; acute oedema glottidis after potassium iodide, Groenouw, 
21; case of tibro-sarconia of the right nasal fossa, with unusual 
clinical history, Knight, C. H., 34; adenoid tissue in the naso- 
pharynx, a preliminary report on the development and early his- 
tory, Swain, H. L., 35; supplemental report on cartilagious tumors 
of the larynx and warty growths in 1 he nose, lngals, E. F., 35; case 
of myxoma of the epigiottis, Van der Poel, S. O., 35; hoarseness and 
loss of voice caused by wrong vocal method, Langmaid, S. W., 36; 
the condition known as chorditis tuberosa, Rice, C E., 36; unilateral 
paralysis of the crico-arytenoid muscle, lngals, E. F., 36; a case of 
unilateral paralysis of the larynx, the result of au attack of bulbar 
disease, with unusual symptoms. Bosworth, F., 36; on the early- 
diagnosis of malignant disease of the larynx, Delavan, D. B., 37; 
the auscultatory percussor, Seaman, L. L., 63; cardiac dyspnoea, 
91; the gross anatomy of chronic pulmonary consumption in rela- 
tion to diagnosis and prognosis, Roosevelt, J. W., 205; paroxysmal 
pulmonary oedema in chronic albuminuria, Bouveret, 211; the 
treatment of pseudo-membranous laryngitis by mercurial fumiga- 
tion, Law, G. E., 235; consumption in Massachusetts, French, J. M., 
340; influenza in the out-patient department of the Boston City 
Hospital, Buckingham, E. M., 343, 348; Professor Flint's doctiine 
of the self-limitation of phthisis, Porter, W., 418; cough, its rela- 
tion to intra-nasal disease, Thrasher, A. B.,419; consumption in 
Massachusetts, Stetson, G. R., 454; Koch's cure for consumption, 
474; the continuous inhalation of oxygen in cases of pneumonia 
otherwise fatal, and in other diseases, Blodgett, A. N., 481, 493; 
sudden death, probably from oedema of the glottis, Minot, F., 536, 
510; the surgical treatment of empyema, Goggans, J. A., 570; manip- 
ulation of the nasal mucous membrane, Cederscbiold. 577; congen- 
ital deformity of the nose, Bradford, E. H., 586; enormous hyper- 
trophy of the nose, Monks, G. H., 592; is the unity of phthisis an 
established fact? an important consideration in regard to the cure 
of the disease by inoculation, Gibbes, H., 608. 

Responsibility of the physician for experiments upon patients, 
even with the latter's consent, 283. 

Rheumatism. Electricity for rheumatism, 382. 

Rhinoplasty, A case of rhinoplasty, Cook, G., 226. 

Ric e, C. E. The condition known as chorditis tuberosa, 36. 

Rider, 0. E. The winking test, 137. 

Rhtlon, J. A report of sixty-two cases of hip disease observed in 
the practice of Hugh Owen Thomas of Liverpool, 327. 

Richards, H. Mastoid sclerosis as illustrated by a typical and 
fatal case, 110. 

Richardson. B. W. The reign of good Queen Bess, 308; the diaph- 
anous test of death, 332. 

Richardson, M. II. A successful case of gastrotomy for removal 
of foreign bodies, 177, 183; suppurative Inflammation of the knee- 
joint treated by drainage through the popliteal epaco, 277; small 
tumor of the upper jaw, 325. 

Richardson, W. I,., and Sinclair, A. 1). Measurements of the 
uterine cavity in child-bed, 444. 



INDEX TO VOLUME CXXM. 



zi 



Richfield Spring*. Tho treatment of dermatological cases by sul- 
phur water at Wiohtield Springs, Ransom, C. C, 255. 
Ricketts, 15. M. Some observations on bono and skin grafting, 523. 
Kick"! I h, K. Surgery of tlie gall- bladder, 569. 

Risley, S. i> , and Randall, I!. A. Cyst of the iris following a pen 
etrating wound at the corneal margin which caused sympathetic 
neuro-relinitis, 161. 

Road-help for the country doctor, Potter, S. O. L., 551. 

Roberts, \v. <). Kenioval of stone from female bladder through 
the urethra, with cases, 567. 

Robertson, J. A. Pregnancy after the removal of both ovaries, 129, 

Robinson, \V. Ij. The treatment of general septic peritonitis, 516. 

Roe, J. <). An instrument for removing glandular hypertrophic 
from the tongue, 12; a case of stricture of the oesophagus from in- 
terstitial thickening of its walls, 37. 

Roosevelt, J. W. The gross anatomy of chronic pulmonary con- 
sumption in relation to diagnosis and prognosis, 205. 

Botch, T. M. Report on diseases of children, 103, 587, 614. 

Russell, W. Unilocular papillomatous cyst of the left ovary, 156. 

Rybalkin, I. V. Blistering by hypnotic suggestion, 333. 

Sachs, B. Tumor of the quadrigetninal region with special refer- 
ence to ocular symptoms, 89; crus lesions, 90. 

Salol. Cases of cystitis treated with salol, Abbot, S. L., 57. 

Santa, I). P. Cholera in Spain, 94. 

Sayre, R. H. A case of congenital lock-jaw, 274. 

Scala and Alessi. Tho micro-organisms of standing water, 551. 

Schenck. A case of tetany, 333. 

Sell in id, E. Hypnotism, 470. 

Schools. Hygiene in tho public schools, Chapin, H. S., 472; physical 
training in the Boston public schools, 548. 

Scudder, C L. The strength of the back muscles of one thousand 
one hundred and forty one of the school girls of Boston, 327; a de- 
termination of the muscular strength of growing girls and its rela- 
tion to the etiology, treatment and prognosis of cases of lateral 
curvature of the spine, 436. 

Seaman, L,. I,. The ausculatory percussor, 63. 

Seegen, I. The treatment of diabetes mellitus, 263. 

Seguln. K. C. Early diagnosis of some serious diseases of the ner- 
vous system, its importance and feasibility, 605. 

Sennander, K. G. Cases of erysipelas of the pharynx, 357. 

Sewage. The Berlin water and sewage works, Virchow, K., 189. 

Shalt nek, F. C. A case of malignant endocarditis secondary to 
colilis, remarks, 79, 84. 

Shattnck, G. B. Influenza in Massachusetts, 25,49,73,97; a case 
of considerable cerebral hemorrhage without symptoms, 324. 

Shaw, S. K. Syringomyelia? 571. 

Shepherd, F. j. A case of atropia maculosa et striata following 

typhoid fever, 254. 
Shoulder. Amputation at the shoulder-joint for sarcoma, Porter, 

C. 15., 181; a new method for treatment of injuries to the shoulder, 

Monks, G. H., 183. 
Sinkler, W. A case of insular sclerosis in which an attack of cere- 
bral hemorrhage arrested the tremor on the hemiplegic side, 91. 
Skene, A. J. C. Injuries to the urete>s during labor, 399. 
Skin-grafting. The use of skin from puppies in skin-grafting, Van 

Meter, M. E., 282. 
Sleep. Disorders of sleep, insomnia, Folsom, C. F., 2, 29. 
Sleeping Sickness. African sleeping sickness, Mackenzie, S., 601. 
Sniiih, A. H. A case in which cerebral localization was illustrated 

by the effect of mental impression, 45. 
Smith, J. L. Appendicitis, typhlitis and perityphlitis in children, 

564. 

Smith, W. E. Some of the relations of climate to health and dis- 
ease, 149, 173. 

Societies, American Association of Genito-Urinary Surgeons, 14, 
38; Americau Dermalological Association, 252; American Gyne- 
cological Society, 350, 375, 397, 420, 443; American l.aryngological 
Association, 10, 34; American Neurological Association, 41, 60, 88; 
American ophthalmological Society, 135, 159; American Ortho- 
pedic Association, 303, 327; American Otologieal Society, 110; 
American Public Health Association, 619; Boston Society for Med- 
ical Improvement, 84, 250, 325, 441, 465, 537; Boston Society for 
Medical Observation, 277, 301, 348, 493; Massachusetts Medical 
Society, 106; Massachusetts Medical Benevolent Society, 526; Mis- 
sissippi Valley Medical Association, 417, 446; New Hampshire 
Medical Society, 155; New York Academy of Medicine, 63, 86, 274, 
396, 523, 593, 616; New York County Medical Association, 184, 204, 
471, 495, 541, 564; New York Neurological Association, 570; New 
York State Medical Association, 468, 520; Obstetrical Society of 
Boston, 59, 423, 525; Rhode Island Medical Society, 394; Southern 
Surgical and Gynecological Association, 567; Suffolk District Med- 
ical Society, 132, 181, 227, 368, 592. 

Spermiu, 578. 

Spine. Spinal surgery, a report of eight cases, Abbe, R., 63, 86. 
Spitzka. Pons lesions in their relations to associated eye movement 

paralysis, 89. 
Spring, C. W. A hydrophobia scare, 388. 
Standish, M. Recent progress in ophthalmology, 533. 
Stanley's estimate of his doctor, 70. 

Stedman, C. E. Malignant endocarditis, death, autopsy, 82, 84; 
appendicitis, operation, hernia, recovery, 299, 302; cancerous liver, 
325. 

Stein, A. W. A case of congenital malformation of the urethra, 16. 
Stelwagon, H. W. Plica, 255. 
Sterility, 477. 

Stetson, G. R. Consumption in Massachusetts, 454. 

Stone, A. K. Clinical value of the bacillus of tuberculosis, 515. 

Strong, C. P. Cases illustrative of some of the more unusual forms 

of bladder disease among women, 53, 59. 
Sugar. A new and rapid test for sugar, Becker, 309. 
Surgeon-general. The new surgeon-general, 210. 
Surgery. Three cases of surgery, Cook, G., 157; report of recent 

progress in surgery, Burrell, H. L., and Cushing, H. W., 319. 
Swain, H. L. Adenoid tissue in the naso-pharynx, a preliminary 

report on the development and early history, 35. 
Syphilis. Peripheral neuritis of syphilitic origin, Fordyce, J. A., 

39; the necessity ior social and statute recognition of syphilis. 
Fisher, C. I., 101, 106; the control of syphilis, 115; infrequency of 



syphilis in Knglish country practice ; Freer ; A., 234; hereditary 
Bypbilis, 262; calomel plaster for syphilis, Quiiiquaiid, 476. 

Tmicil, A. W. Traumatic tetanus, recovery, 478. 

Taylor, H. I,. Method of making counter-traction at the knee- 
joint, 304; a ready method for counter-extension of the knee, 861; 
the treatment of lateral curvature, 327. 

Taylor, R. W. Observations on prurigo, clinical and pathological, 
253; a case of secotid infection with syphilis, and a case of syphilitic 
infection in a person hereditarily syphilitic, 255. 

Teissier. Intestinal antisepsis in typhoid fever, 476. 

Tetanus. A cane of congenital lock-jaw, Sayre, R. H., 274; a case of 
tetany, Schenck, 333; strychnine as an antitctanic vaccine, Pey- 
raud, 178; traumatic tetanus, recovery, Tancil, A. W., 478; inocula- 
tion for diphtheria and tetanus, 575. 

Theobald, S. A case in which a septum closely resembling the 
tympanum membrane formed in the middle third of the external 
auditory canal, and was removed with improvement to hearing, 111 ; 
a case of recurrent irido-choroido retinitis, 160; three noteworthy 
cases of ametropia, 100. 

Thomson, J. C. Chinese medical practice and practitioners, 501. 

Thrasher, A. B. Cough, its relation to intra-nasal disease, 419. 

Thyroid Gland- Extirpation of the thyroid gland, 263. 

Tinkham, G. W. A case of haemophilia as observed at the first 
menstrual period, 525. 

Todd, C. A. Aneurism first recognized in the fundus of the ear' 
later appearing In the neck, 112. 

Tonsil. Case of sarcoma of the tonsil removed by external incision, 
recovery, Homans, J., 433. 

Torsion of arteries as a means for the arrest of hemorrhage, Mur- 
dock, B., 420. 

Townsend. Ninety cases of dysinenorrhcea and sterility treated by 
rapid dilatation of the cervical canal, 166. 

Townsend, C. \V. A case of haemophilia as observed at the first 
menstrual period, 516, 525. 

Townsend, VV. R. Rachitic posterior curvature of tibiae, 275. 

Tuberculosis. A case of tubercle inoculation, 381; certainty in the 
diagnosis of tuberculosis, Potter, T., 446; the surgical treatment of 
tubercular peritonitis, 453: Koch's cure for consumption, 474; tuber- 
cle bacilli, Gibbes, H., and Shurly, K. L.,487; Koch's treatment for 
tuberculosis, 497, 574, 598; clinical value of the bacillus of tuberculo- 
sis, Stone, A. K., 515; inoculations for pulmonary tuberculosis, 
liol.lt, H. J., 567. 

Tyndale, T. H. A plea for physical diagnosis, 249. 

Typhoid Fever. On the transmission of typhoid fever by the air, 
Bordas, 141; intestinal antisepsis In typhoid fever, Teissier, 476. 

Ulrich. Treatment of erysipelas, 501. 

United States Marine-Hospital Service. Medical inspection of 
imuiigrants by consular physicians, 71. 

Urie, J. F. A case of gun-shot wound of important abdominal vis- 
cera with recovery, 318. 

Urinary System. A case of severe hsematuria, nephrectomy by Dr. 
McBurney, recovery, Brown, F. T., 14; a case of cystitis, with the 
formation of a thick epidermal sheet in the bladder, Cabot, A. T., 
14; a case of suprapubic lithotomy and prostatectomy, White, J. 
W., 15; notes on the technique of suprapubic cystotomy and pros- 
tatectomy, Belfield, W. T., 15; removal of the third lobe of the 
prostate, with complete restoration of the functions of the bladder, 
Otis, F. N., 15; tibro-myoma of the male pelvis, Rludd, H. G., 16; a 
case of congenital malformation of the urethra, Mudd, H. G., 16; 
a memorandum in a rare complication of litholapaxy. White, ,1. W., 
38; a case of cyst of the kidney apparently cured by a single aspira- 
tion, Cabot, A. T., 39; a case of extrophy of the bladder, with pho- 
tographs, Cabot, A. T., 39; a method of employing antisepsis in 
anterior urethritis, White, J. W., 40; cases illustrative of some of 
the more unusual forms of bladder disease among women. Strong, 
C. P., 53, 59; cases of cystitis treated with salol, Abbot, S. L., 57; 
large papillomatous cyst with ascites, laparotomy, wound of the 
bladder which lay unusually high, suture of it, with complete re- 
covery, Cabot. A. T., 83, 84; piece of catheter in the bladder, Cabot, 
A. T., 84; vesical calculus removed by vaginal lithotomy, Daven- 
port, F. H., 204; the treatment of cystitis in women, Madden, T. M., 
211; paroxysmal pulmonary oedema in chronic albuminuria, Bou- 
veret, 211; a successful case of uretero lithotomy for an impacted 
calculus, Cabot, A. T., 247; atropia in the treatment of enuresis, 
James, J. B.. 261; a large surgical cyst of the kidney, Irwin, F., 
278; suprapubic lithotomy in a boy of twelve. Post, A., 393; injuries 
to the ureters during labor, >kene, A. J. C, 399; oxaluria and ner- 
vous states, 103; incontinence of urine due to malposition of the 
ureter, Davenport, F. H., 420; perineal cystotomy VS. suprapubic 
cystotomy, Walker, H. O., 447; resume of experience to date, all 
over the world in the various operations for cystitis from prostatic 
hypertrophy, Belfield, W. T., 447; treatment of organic stricture of 
the male urethra, Norman, S., 448; retention of urine from pros- 
tatic obstruction in elderly men, its nature, diagnosis and manage- 
ment, Gouley, J. W. S., 471; notes on the non-operative treatment 
of enlarged prostate, Cabot, A. T., 529, 537; suprapubic cystotomy 
in a case of enlarged prostate, Cobb, W. H. H., 544; removal of stone 
from female bladder through the urethra, with cases, Roberts, W. 
O., 567; value of cystoscopy in the diagnosis of surgical diseases of 
the kidney, Newell, O. K.. 591; another successful case of uretero- 
lithotomy, Cabot, A. T., 613. 

Vance, A. M. Amputation as an orthopedic measure, 303. 

Van der Poel, S. O. Case of myxoma of the epiglottis, 35. 

Van Meter, M. E. The use of skin from puppies in skin-grafting, 282. 

Varicocele. A review of the treatment of varicocele, Lydston, G. 
F., 569. 

Vickery, H. F. Two unusual obstetric cases, 412; menorrhagia in a 

patient afflicted with haemophilia, 520, 525. 
Virchow. The Berlin water and sewage works, 189; the seventieth 

birthday of Professor Virchow, 600. 
Voice. Hoarseness and loss of voice caused by wrong vocal method, 

LaDgmaid, S. W., 36. 
Von Stein. The electric light as an analgesic, 453. 
Wadsworth, O. F. Thrombosis of the arteria centralis, central 

vision unaffected , 161 ; the ti'sufficiency of the ocular muscles, 349; 

a case of metastatic carcinoma of the choroid, 489; thrombosis of 

arteria centralis retinse, large retino ciliary artery, central vision 

unimpaired, 559. 



xii 



INDEX TO VOLUME OXXIII. 



Walker, E. Two cases of tubal pregnancy, 447. 

Walker, H. O. Perineal cystotomy vs. suprapubic cystotomy, 447. 

Walton, G. t,. Traumatic neuro-psychoses, 61); electricity for rheu- 
matism, 382; fatal case of lead poisoning in which ataxia was the 
principal symptom (pseudo-tabes), 411. 

War. Some aspects on our medical service in the War of the Rebel- 
lion, Lyman, G. H., H5. 

Water. The Berlin water and sewage works, VIrchow, 189; perox- 
ide of hydrogen a9 a disinfectant of water, Altehoefer, 477; the 
micro-organisms of standing water, Scala and Alessi, 551. 

Weather. The diet of hot weather, 187. 

Wendt, E. C. Craniectomy for microcephalic cretinism, 238. 
Wheeler, I>. Two cases of laparotomy for tubercular peritonitis, 241. 
White, J. C. Immigrant dermatoses, 254. 

White, J. W. A case of suprapubic lithotomy and prostatectomy, 
15; a memorandum in a rare complication of litholapaxy, 38; a 
method of employing antisepsis in anterior urethritis, 40. 

Whitney, W. F. Osteo-chrondro-myxoma of the right thigh, 85. 

Whittier, E. N. Heart failure, 222, 227. 



Wilder, B. G. Demonstration of some special anatomical charac- 
teristics in the brain of a distinguished Scientist, 89. 

Willard, De F. Address before the American Orthopedic Associa- 
tion, 303. 

Williams, F. H. Report on progress in therapeutics, 490, 518. 
Wilmarth, J. The country doctor, 142. 
Wilson. J. T. Uterine moles and their treatment, 568. 
Wilson, K. A case of greatly prolonged gestation, 94. 
Withington, C. F. Some extra-medical manifestations of hysteria, 
193. 

Women's scholastic honors, 94. 

Wood, W. B. After-treatment of obstetric cases, 204. 
Woodbury, F. Infectious dyspepsia and its rational treatment by 

the antiseptic method, 417. 
Woodbury, J. McG. Hip-joint disease after typhoid fever, 617; a 

case of osteo malacia, 617. 
Wyeth, J. A. The medical student, 419. 
Wyman. The prevention of phthisis, 620. 

Young, J. Diseases of the eye associated with spinal caries, 327. 



V 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



1 



THE BOSTON CITY HOSPITAL. 1 

BY CLAllKNCK J. BLAKE, M. D., BOSTON. 

Fokty-onk years ago, in Boston, with a population 
of one hundred and thirty-six thousand, the principal 
provision for the house care of the sick poor, other 
than that to he found in their own homes and in public 
institutions, was afforded by the Massachusetts General 
Hospital; the larger part of the out-patient service of 
the city being shared by it with the Boston Dispensary 
and, for special cases, the Massachusetts Charitable 
Eye and Ear Infirmary. At that time, in 1849, an 
epidemic of cholera made especial call upon the hos- 
pital resources of the city, and stimulated the demand 
for more accommodation of this kind; the project for 
the establishment of a City Hospital first took shape, 
was earnestly favored by the principal physicians in 
the town, one of whom wisely suggested the reserva- 
tion of city land for that purpose, and there was 
prospect for speedy realization, but, the cholera sub- 
sided, the necessary order passed by the Board of 
Aldermen was lost in the Common Council and the 
hospital without its reserved land to build even a hope 
upon existed only as a purpose in the minds of those 
of the medical profession who, working among the 
sick poor, best appreciated the need existing and to 
come. This purpose found its voice again in 1856, when 
the medical profession and the officers of charitable 
institutions, uniting, urged upon the public in various 
ways and upon the Council of 1857, through the earn- 
est advocacy of the then Mayor, Hon. Alexander H. 
Rice, the importance of establishing a hospital which 
should be at the service of the inhabitants and under 
the control of the government of the city, but the 
objection made by certain citizens to the use, as was 
proposed, of the Lying-in Hospital in Springfield 
Street again blocked the way, and it was not until 
1860 that the land at present so fully and usefully 
occupied was appropriated for that purpose, and in 
the following year the foundations for the buildings, 
to consist of a central structure, two wings or pavilions, 
and in the rear of the centre the necessary boiler and 
engine rooms and laundry, were begun. 

In May, 1864, the hospital was first opened for the 
reception of patients, one of the pavilions being de- 
voted to medical and the other to surgical cases, the 
house-officers, resident graduates as they were called, 
two in each department, dividing the service between 
them by an imaginary line, running the length of each 
pavilion from top to bottom, the single rooms in the 
basements being used as examination and accident 
rooms and for isolating purposes. 

The conditions of that first year's service as necessa- 
rily imposed upon the visiting staff were most onerous, 
a new building, inexperienced house-officers and un- 
trained nurses, a lack of definition of the authority of 
the staff, which had to insist, in a building still in 
part in progress of construction and not yet fully 
in running order, upon the "benefit to the patient" as 
the primal object of its existence ; these made a com- 
bination of difficulties met and overcome with a patient 
persistence which laid the foundation of the present 
success of the hospital as a medical institution. 2 

1 Read at the Annual Meeting of the Boston City Hospital Club, 
June 10, 1890. 
- The visiting and resident staff, 1864 : 

Visiting physiciaus. t W. W. Morland, M.D.; Fitch Kdw. Oliver, 



The first hospital year was of but seven months du- 
ration, and within that time there were 475 patients 
admitted, 129 accident cases received and 271 out- 
patients treated ; in the next year, 1865, there were 
1,066 patients admitted, 242 accidents and 1,143 out- 
patients ; in 1875, 3,424 admitted, 756 accidents and 
8,732 out-patients ; in 1885,4,031 admitted, 676 ac- 
cidents and 12,005 out-patients; while, in the year 
just ended, there were 6,157 patients admitted to the 
house, 888 accident cases received and 13,605 people 
treated as out-patients. 

A review of the table in the comprehensive and 
valuable report of the superintendent, 8 from which 
these figures are taken, shows that while the increase 
in house-patients has proceeded at a fairly steady pace, 
the number of out-patients was less by 636 than in 
1884, eighteen years only after the opening of the out- 
patient department. 

A consideration of the growth of the buildings of 
the City Hospital during the past twenty-five years 
will serve to explain this apparent discrepancy. Be- 
ginning in 1864 with the central buildings and wings, 
which had been expected to afford ample provision 
for at least a decade to come, in 1872, eight years 
later, the justifiable demand upon the hospital was so 
great that, in addition to the beds provided for small 
pox patients in buildings on the water side of Albany 
street, beds were placed in the private rooms and in 
every other available spot to the extent of fifty more 
than the original provision. The dangers of an over- 
crowded hospital were fully appreciated by the visiting 
staff, now increased in uumbers, and in their report of 
that year they set forth the need of more ward room 
for both medical and surgical cases, adequate reception 
rooms for accident and for lying-in cases, and the 
substitution of a suitable operating amphitheatre for 
that which, situated in the dome of the rotunda and 
necessitating lengthy transportation of patients, had 
sufficiently demonstrated its unfitness in the surgical 
experience of the first year. In 1873-74, a medical 
superintendent having been in the meantime appointed, 
the overcrowded condition of the hospital was again 
reported and the especial need of better surgical 
accommodation in the out-patient department as well 
as in the house was urged, and was met by an appro- 
priation ($190,000), made by the City Council in that 
year for the "enlargement or extension of the build- 
ings," the result being the addition of two main build- 
ings for medical and surgical cases respectively, two 
one-story buildings and a kitchen building, the whole 
giving an increase in house accommodation of eighty- 
five beds. In the same year the drainage, plumbing 
and ventilation were thoroughly overhauled, and the 
single rooms in the basements of the pavilions, half 
underground, were abandoned as wards, for obvious 
sanitary reasons. 

At the beginning of its second decade, therefore, 
the hospital had five new buildings, a considerable 
increase in its accommodations in the house, and a 
proportionate enlargement of its working staff, there 

M.D.; J. Baxter Uphain, M.D.; J. N. Borland, M.D.; J. G. Blake, 
M.D.; John P. lieynolds, M.D. 

Visiting surgeons. tC. H. Stedman, M.D.; t C. E. Buckingham, 
M.D.; tD. McB. Thaxter, Jr., M.D.; t Charles D. Homans, M.D.; 
Algernon Coolidge, M.D.; David W. Cheever, M.D. 

Resident graduates. Medical: tJohn Dole, M.D.; ClareDce J. 
Blake. Surgical : M. F. Gavin, M.D.; 1). F. Lincoln, M.D. 

Ophthalmic Surgeon, Henrv W. Williams, M.D.; Admitting Physi- 
cian, t Howard F. Damon, M.D.; Pathologist, Charles W. Swan, M.D.; 
Ophthalmic Externe, Edw. G. Loring, M.D. 

Those with the dagger (t) prefixed have since died. 

» Twenty-sixth Annual Keport, Boston City Hospital. 



2 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 3, 1890. 



being ten out-patient surgeons and physicians and 
thirteen house-officers, five of that number acting as 
externes. 

In 1878 the work of overhauling the old pavilions 
and correcting the defects in arrangement was fairly 
completed, and another step had been taken in the 
development of the hospital upon a scientific basis in 
the establishment of the training-school for nurses 
which, in addition to the public benefit afforded by it 
outside of its own walls, has served to provide effi- 
ciently for one of the most important needs in the 
successful conduct of a hospital. 

At the end of the first year there were in the hos- 
pital three head-nurses, graduates of the training- 
school, nine other head-nurses in charge of wards, 
twenty-seven assistant or pupil nurses and eight others 
not belonging to the school. The number of graduates 
the first year of the school was six and in 1889 
twenty-eight. The number of nurses employed to- 
day in the hospital work is seventy-seven. 

In 1879 the reservation of additional land was ad- 
vised ; in 1 880 the need of a separate building as a 
home for the increasing staff of nurses was recom- 
mended and the ambulance system, improved in previous 
years, was well established. 

At the end of its second decade the hospital, while 
enlarged, as has been said in its main departments, had 
only the same accommodations for contagious cases 
as that provided in 1866, seventeen years before ; the 
population of the city had in the same time iucreased 
over fifty per cent., and the nurses, crowded out by 
the demands for room for patients, were most inade- 
quately lodged, and the out-patient department equally 
cramped for want of room, now numbered eight ser- 
vices and received over 40,000 visits per annum. In 
1886 the house capacity had been increased to 425 
beds, and in the annual report for that year it was 
shown that over 44,000 out-patient visits had been 
received and treatment given in a building, which was 
justly stigmatized, because of its want of accommo- 
dation, as "a great blemish and the most disagreeable 
feature of the hospital establishment " ; on the other 
hand, the nurses' home had been in the meantime 
completed and was giving satisfactory evidence of its 
usefulness, and the new contagious wards which were 
completed two years later were projected. 4 

As it stands to-day, the City Hospital has nine 
large buildings devoted to the accommodation of 

© o ... 

patients, and additional buildings for administration, 
cooking, heating, and otherwise providing for the 
maintenance of the medical service, two out-patient 
buildings and a nurses' home, it has 480 beds for pa- 
tients and these are usually full, it has, in addition to 
its large amphitheatre, smaller operating rooms in con- 
nection with wards in certain special departments of 
its house service ; 8 its new out-patient building is ad- 
mirably equipped in all respects. There is a visiting 
and consulting medical and surgical staff, numberiug 
twenty-four members, an out-patient staff of twenty- 
live, and a staff of house-officers which will be in- 
creased after July 1st next, to twenty-two; fifteen in- 
ternes and seven externes. 

While all of this growth has had in view the primal 
object of such an institution, in the relief of human 
suffering, that other and equally esseutial duty of a 

* During tho past year 210 cases of diphtheria and 88 of scarlatina 
wore t reated in these wards. 

• The number of surgical operations ill 1864 was 464 ; during the 
last year, 1,116, 



hospital, the furthering of medical education has been 
kept in mind. In the very first rules and regulations, 
this function is recognized in the clause setting forth 
the conditions under which students may be admitted, 
and the provisions made for this purpose and the op- 
portunities afforded for clinical instruction in the 
present City Hospital make it, in this respect, the 
equal of any hospital in this country, so far as I am 
aware. It has all the material and nearly all the 
provisions of a great educational institution, and the 
spirit of progress is shown in the further improve- 
ments already in contemplation, which include pro- 
vision for discharged convalescents, the still more 
exact isolation of and provision for contagious cases 
and for the study of such diseases as may come under 
this head, and the erection of a fireproof building for 
the preservation of the clinical records, which already 
make a substantial library of over eight hundred 
manuscript volumes, containing the detailed records 
of more than one hundred thousand cases. As a 
supplementary library the morgue and autopsy room 
furnish already thirteen volumes of records of autop- 
sies, of which the average during the past winter was 
sixteen a month, in addition to medico-legal examin- 
ation. 

In relation to the use of selected material for in- 
struction, the City Hospital affords, therefore, not 
only in its large number of house cases 6 and its valu- 
able records, but also in its new out-patient buildings, 
where arrangement is made for the accommodation of 
student as well as patient, 7 an opportunity which is 
individually sufficient for a most thorough and com- 
plete system of clinical instruction. 



Original 3Urttde£. 



DISORDERS OF SLEEP: INSOMNIA. 1 

BY CHAS F. FOLSOM, M.D., CO-REFEREE, 

Visiting Physician to the Boston City Hospital. 

In studying the disorders of sleep I have confined 
myself to insomnia, partly because of the inherent 
difficulties and extent of the subject ; partly as my 
material is so crude and undigested as regards the 
more abstruse phenomena, that I have left them to the 
wider experience of our referee, who, as Schiller said 
of Goethe, need only shake the limbs to have the 
mature fruit of a ripe knowledge fall in abundance. 
I find that nearly every physiologist has attempted 
some theory of sleep, without adding materially to 
our knowledge why or how we sleep, although the re- 
sult has been to indicate many of the phenomena 
which occur while we sleep. Duval calls the suspen- 
sion of cerebral activity in sleep a function of the 
brain — the passive condition following the active as 
regularly as an interval of rest succeeds the heart- 
beats. Lasegue speaks of the appetite for sleep, 

1 A paper read at tho meeting of tho Association of American Phy- 
sicians, Washington, May, 1890. 



8 For purpose of comparison may bo mentioned the in-patient ser- 
vices of the following hospitals connected with medical schools : 
New York Polyclinic, 40 beds; New York Post-Graduate Hospital, 
85 beds ; Bellevue Hospital, 800 beds ; Long Island College Hos- 
pital, 100 beds ; Jefferson Medical College Hospital, 125 beds ; Uni- 
versity of Pennsylvania Hospital, beds. 

' The number of out-patients (new cases) treated last year wore : 
medical, 8,138 ; surgical, 5,823 ; diseases of eye, 1,542 ; diseases of ear, 
.'S95 ; diseases of skin, 053 ; diseases of women, 577 ; diseases of ner- 
vous system, 538 ; diseases of throat, 644. 



Vol. CXXIII, No. 1.] BOSTON MEDIO AL AND SURG 10 AL JOURNAL. 



3 



which others liken to hunger and thirst. We certainl y 
explain nothing if we say that drowsiness arises from 
exhaustion of the activity of the brain cells, or, with 
Landois, that sleep is due to the using up of the po- 
tential energy, especially in the central nervous sys- 
tem, making restoration of energy necessary. Nor 
do we go much farther in speculating on the existence 
of a sleep-centre in the brain. The chemical theory 
of Obersteiner and Preyer, that the acid waste-products 
produced by the activity of the brain finally reach a 
degree sufficient to arrest it, and thereby cause sleep 
until their elimination, is only less satisfactory than 
Pfltiger's view, based upon experiments by Pettenkofer 
and Voit, and the oxygen hypothesis. The lessened 
amount of blood in the brain during sleep, as shown 
by the plethysmograph and otherwise, like the slowed 
pulse and respiration, cannot be held to be an ante- 
cedent cause of sleep, and the increased alkalinity of 
the blood from greater proportionate elimination of 
carbonic acid naturally explains nothing in that direc- 
tion. 

What happens in the brain when we sleep is de- 
scribed from a psychological point of view by Mercier, 5 
following Hughlings Jackson and Herbert Spencer, as 
follows : The molecules that were shifted into new 
positions are still oscillating from the shock. Those 
that were only slightly disturbed are returning to 
their original positions ; those that were profoundly 
moved are settling in their new places, presenting 
more stable attitudes to the action of surrounding 
forces. Regions that perhaps after long repose were 
disturbed in the day still continue to emit a mild re- 
verbration of their discharge, and the passage of cur- 
rents at random through the highest regions under 
the sole influence of irregularities of pressure, and 
without guidance from external impressions, has its 
mental counterpart in the phenomena of dreams. 

On the pathology or psychology of wakefulness, I 
have nothing with which I feel justified in taking the 
time of the Association. Indeed, the subject in gen- 
eral is difficult of concise treatment or scientific ar- 
rangement, and analysis of cases proves unsatisfactory. 
An examination of my records indicates the following 
causes or conditions of insomnia, each one of which 
might be easily expanded into an essay by itself : 

(1) The perverse habit of sleeplessness, a result of 
years, perhaps generations, of misuse of body and 
brain, 1 hardly need mention ; and scarcely more the 
habits formed to induce sleep, as regards light and 
darkness, noise or stillness, idiosyncrasies of position, 
temperature, etc. These people always are amazed to 
see how much can be done to form the habit of sleep ; 
what fair sleepers they may finally become by the 
proper kind of training. 

(2) Insomnia from external causes, through the 
various senses, excluding habit, naturally includes the 
obvious natural sensations of heat, cold, pain, hunger, 
light, noise, etc. 

(3) Excessive intellectual or emotional activity, in- 
cluding strain, excitement — pleasurable or distressing 
— grief, fear, worry, anxiety, etc., if sufficiently intense 
or prolonged. Naturally, as elsewhere, excess is 
only a relative term in different individuals, or in the 
same individual under different conditions. With 
the forced overaction of the brain the nervous dis- 
charge, as time goes on, requires greater stimulation 
until such a degree of exhaustion and instability is 

2 The Nervous System aud Braiu, p. 374. 



produced that any natural function, even rest or 
sleep, for a time becomes fragmentary, insufficient, or 
almost impossible. 

(4) Of the reflex causes of insomnia, indigestion, 
gastric or intestinal, is by far the most common, and it 
may fail to be indicated in any of the usual ways. As 
in persistent headache, a cause may be discovered 
only after repeated experiment in withdrawing one 
article of food after another, until the offending one 
is found. Genito-urinary and pelvic disorders come 
next, with unlimited possibilities thereafter. 

(5) The traumatic antecedents of insomnia are 
purely physical, from a sudden fall or blow, for 
instance; psychical, as in violent mental shock; or 
both, such as occurs in railroad accidents, etc. In 
these cases there is evidently a wide difference in the 
degrees of injury to the brain. The impression may 
be transient and resulting in restoration to healthy 
function. It may consist, in almost any degree, slight 
or great, of disarranging, decomposing, decompounding 
of cerebral molecules and cells, possibly of association- 
tracts, sometimes resulting, as Westphal held, in minute 
patches of sclerosis, 

(6) The auto-toxic sources of insomnia in acute 
diseases need only bare mention ; in chronic disease, 
gout, lithaemia, rheumatism, tuberculosis, syphilis, ma- 
laria, leukaemia, and chronic nephritis, there is a 
similar cause independent of any cerebral exhaustion 
or impaired nutrition which may be produced by them. 
Probably much at least of the sleeplessness from 
habitual constipation belongs in this category. I have 
often found persistent wakefulness an early symptom 
of some general disease, especially acute rheumatism 
and arterio-sclerosis, many months before an absolute 
diagnosis became possible. 

The habitual excessive use of tea, coffee, tobacco, 
alcohol, morphia, chloral-hydrate, bromides, cocaine, 
or other drugs, is a fruitful toxic source of insomnia. 
Chronic poisoning from arsenic and from lead, perhaps 
often by leading to vaso-motor disorders, degenerative 
disease, and arterio-sclerosis, without the usual symp- 
toms, must not be overlooked. 

(7) Exhaustion from wasting diseases and enfeebling 
conditions, pulmonary consumption, anaemia, starving, 
profuse and repeated hemorrhages, sexual excesses, 
impaired nutrition of the brain from either deteriorated 
quality or diminished quantity of its blood-supply. 

(8) Of vascular origin, from hepatic disease, pro- 
ducing venous stasis, from cardiac and renal diseases 
with increased vascular tension, from asthma and 
hypertrophied or dilated heart, producing cerebral 
hyperasmia, anaemia or venous engorgement, from ar- 
terio-sclerosis, especially that of old age. Exaggerated 
or insufficient blood-supply to the brain, venous stasis, 
increased vascular tension, may also arise from syph- 
ilitic disease of the bloodvessels, or from disorders of 
digestion or of the portal system, and be as fertile a 
source of insomnia as the disturbances in the circula- 
tion in women at the menopause and other critical 
periods in life, including puberty, pregnancy, child- 
birth and lactation. Here also there may be disordered 
innervation, as well as disturbed vascular tension aud, 
perhaps, nutrition, such as we often see in less degree 
during menstruation. 

(9) Vaso-motor. — In that marvel of scientific re- 
search and profound medical knowledge, Meynert's 
Erkrankungen des Vorderhirns, the author repeats a 
statement previously made by him, that the nutrition 



4 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 3, 1890. 



and the Erregbarkeitsverhdltnisse of the brain depend 
upon its relative weight, as compared with the weight 
of the heart. The blood- pressure, however, is natu- 
rally not governed solely by the heart and cardiac 
innervation, but by the resistance which the cerebral 
capillary vessels offer by virtue of their vasocon- 
strictor nerves, thus bringing in the higher automatic 
vaso motor centres of the cortex, which are subject 
also to psychical influences, and the reflex vaso-motor 
centres in the pons and medulla as well as the asso- 
ciations-tracts, the reflex vaso-motor centres of the 
spinal cord acting only coordinately or subordinately. 

This field of study is too broad to be entered upon 
understanding^ in the present state of our knowledge. 
That vaso-motor paresis constitutes an important fea- 
ture of the prodromal period of diffuse cortical ence- 
phalitis, and probably of other organic disease, as well 
as in the neuritis of lead and arsenic, must, I thiuk, 
be admitted. The theory that there is a disease which 
is essentially of the cerebral vaso-motor centres, in- 
volving, perhaps, the associations-tracts and the spinal 
reflex centres, is one in favor of which much can be 
said, especially where the symptoms appear rather 
abruptly in people in otherwise good health, without 
marked emotional or other exhaustive antecedents, 
and where the least mental or physical effort pro- 
duces marked cerebral and spinal hyperemia. How 
far vaso-dilator nerves act in such cases is a matter of 
doubt, the transient or more or less persistent anasmia 
and hyperemia of the brain and cord being explained 
by excess of functional activity or inhibition of func- 
tion in the vaso-motor centres. 

(10) The neurasthenic cosdition, in exalting the 
direct and reflex excitability of the nervous system, 
naturally intensifies the usual causes and conditions of 
insomnia, the unusual sources of insomnia in neurasthe- 
nia, in my experience, being astigmatism and halluci- 
nations of sight or hearing. The eye-strain from 
astigmatism is often in health unnoticed, when in 
states of debility it produces headache, dizziness, spas- 
modic muscular action, or wakefulness. 

An hallucination of sight occurring a single time is 
not uncommon in people in reasonably good health. 
Frequently repeated, such hallucinations are less rare 
than is supposed without any indications of mental or 
other disease. Occasionally, like flashes of light, they 
are precursors of headache. I have observed frequent 
hallucinations of hearing only once, independent of 
insanity. 

If of distressing nature hallucinations of sight and 
hearing may be a fruitful source of insomnia. They 
occur beyond the power of the will of the individual 
to call them up, although sometimes able, under 
some conditions, to cause them to disappear. The 
hallucinations of sight constitute new arrangements of 
mental impressions which can be more or less clearly 
recollected, or they form combinations which seem 
entirely new. Once I have found two sisters subject 
to them, and once two sisters, a cousin, and a common 
grandmother — curiously enough, the different mem- 
bers of the families not knowing each other's peculiar- 
ities, which, however, were quite different in kind, 
until I began my investigations. They had thought 
them uncanny, and had concealed them. 

(11) The neuropathic temperament, usually by 
inherited predisposition, but which may be acquired. 
In its pronounced form it is closely allied to the well- 
marked functional diseases of the nervous system, and 



at the critical periods of life, may readily develop 
into them. It is congenital, or due to early interfer- 
ence with the normal development of the brain, to 
faulty training, and to bad habits of living. It shows 
itself in infancy and childhood by irregular or dis- 
turbed sleep, irritability, apprehension, strange ideas, 
great sensitiveness to external impressions, disagreea- 
ble dreams and visions, romancing, intense feeling, 
periodic headache, muscular twitchings. There are 
often excessive shyness, introspection and self-con- 
sciousness, or extreme self-assertion or conceit. 
The imitative and imaginative faculties may be quick, 
the emotions strong, the affections intense or almost 
absent. The natural feelings easily become disturbed 
and perverted. The passions are unduly a force in 
the character, which is commonly said to lack will- 
power. Self-discipline is a mighty task, and self-con- 
trol is acquired only with great difficulty. The mem- 
ory is now and then phenomenal. There is a ready 
reaction to external circumstances, even to the weather, 
by which the individuals become easily a little exhila- 
rated or somewhat depressed. They are apt to be 
self-absorbed, and may be. suspicious, or morbidly 
conscientious. Slight physical ailments, hardly no- 
ticed or rapidly recovered from iu sound constitutions, 
leave on them a long or lasting impression. They 
readily become neurasthenic, hypochondriacal, or ner- 
vous invalids, so called, and they break rules or dis- 
regard established customs with less cause or provo- 
cation than other persons. They lack stability, or 
have in special directions narrowed limitations of 
intellectual energy, in quality or quantity. To the 
nervous temperament there may belong social and 
intellectual gifts and graces, originality, intensity, 
poetry, art, philanthropy. Adjusting skill, the ability 
to adjust their organism to their environment, to use 
Herbert Spencer's phrase, is often lacking. 

Many of these people have the marks of Morel's 
degeneres with few compensations ; many illustrate 
that marvellous law of compensation in nature for 
defect in one direction by accomplishment in another. 
Often not only they, but generations before them, 
have been crammed mentally and emotionally but 
starved in other ways, their very abstemiousness pro- 
ducing a tough asceticism, requiring decades before 
the final but sure physical deterioration, or there may 
be a gouty diathesis and the two somewhat opposite 
temperaments or perhaps constitutions may be com- 
bined by intermarriage. They fail to store up nervous 
energy ; they are unable to inhibit the free or exces- 
sive or explosive discharge of it in response to incon- 
sequent excitations, and they are constantly in the 
position of having expended more than their reserve 
nervous force. From the prominence in adult life of 
the unstable emotional centres which predominate in 
childhood, they are most difficult to treat. Most of 
them are insomniacs, more or less, to quote one of the 
most gifted and graceful of them. We can no more 
relieve them of all their symptoms than we can add a 
cubit to their stature. But there are none in the 
community for whom we can do more, as there are 
none to whom alluring promises, including mind-cure, 
faith-cure, hypnotism, etc , are more seductive. 

(12) Wakefulness is one of the most difficult symp- 
toms to treat in the various stages of many forms of 
mental disease, and it is doubtless only an early symp- 
tom in many cases where it had been regarded as a 
cause. In hysteria, hypochondria, and organic dis- 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



5 



eases of the spinal cord and brain, including lnemor- 
rhage, embolism and thrombosis, insomnia often taxes 
our utmost resources. 

(I.'i) As a form of insanity — that is, as an inter- 
changeable psycho-neurosis in families predisposed to 
mental disease — insomnia is not very uncommon, 
especially among Morel's degeneres. In such case 
it is persistent for months or years, is attended with 
great mental and physical exhaustion from slight 
effort, and is most intractable to treatment. It usually 
ends in more or less permanent mental enfeeblement 
with impaired will-power and diminished self-control, 
perhaps without, but generally with, other psychical 
symptoms. 8 

In estimating the value of insomnia as a symptom 
— that is, in establishing a prognosis — it is chiefly in 
neurotic patients that we have great concern ; and 
even in them it seems to me well to always bear in 
mind the distinction which Meyuert draws between the 
large number Zur Krankheit Berufenen and the much 
smaller number of those Zur Krankheit Erwahlten. 

The one organ, excluding organic disease, upon the 
functional health of which I place the first dependence 
in prognosis, is the stomach. 

There are certain obvious indications in the treat- 
ment of insomnia, to amend bad habits, which may 
mean the errors of a lifetime ; to relieve painful im- 
pressions through any of the external senses; to re- 
move depressing mental influences; to cease over- 
work; to interrogate every function and organ of the 
body ; to correct constipation, faults of digestion, 
whether gastric or iutestinal, oxaluria, etc.; to forbid 
unsuitable articles of food and drink ; to meet the 
indications of toxic influences in acute and chronic 
disease, from the abuse of tea, coffee, tobacco, alcohol, 
opiates, chloral, bromides, cocaine, or in poisoning 
from lead, arsenic, and other sources ; to stop excesses 
and build up conditions of exhaustion and anaemia; to 
control as far as possible the vascular disturbances in 
hepatic, renal and cardiac diseases, using leeches as 
needed in venous engorgement or congestive conditions. 

Further than this and treating symptoms, our meas- 
ures must be largely restorative — so little do we know 
of sleep and sleeplessness or understand the pathology 
of the nervous system and its cells with their molecules 
estimated to contain each nearly a thousand atoms 
grouped together in small and large clusters, which 
are again united into larger more or less complex 
groups. 

The amount of sleep needed either in health or dis- 
ease and the injury from loss of sleep, vary so widely 
in different persons that naturally there can be no fixed 
rule for therapeutic interference. Generally speaking, 
the temptation is to resort to medical treatment too 
readily, and to be too much afraid of a few sleepless 
nights. Iu some individuals and in some families, a 
wakeful week, with little sleep each night, is not a 
matter for concern, as compared with acquiring the 
habit of depending upon narcotics ; in others the use 
of sedatives, even for a long time, is attended with 
good results. 

3 If this classification is unsatisfactory, the latest attempted on a 
scientific basis does not better meet the case, stated by Germain- 
See as follows : (1) L'insomnie douloureuse ; (2) L'insomnie diges- 
tive ; (3) L'insomnie cardiaque et dyspneique ; (4) L'insomnie cere- 
bro-spinale, neurosique, comprenant les lesions de l'encephale, la 
paralysie generate, les manies aigues et chroniques, l'hysterie, 
1'hypochondrie ; (5) Les insomnies psychiques (emotives, passionelles 
et sensorielles) ; (6) L'insomnie de fatigue cerebrale et physique ; 
(7) L'insomnie genito-urinaire ; (8) L'insomnie febrile, infectieuse, 
autotoxique. ; (y) L'insomnie toxique (cafe, the\ alcool). 



The hygiene of sleep includes the most minute atten- 
tion to the whole environment of the patient, position, 
change of room or of locality, temperature of the body 
and of the air, diet, digestion, secretions, excretions, 
fresh air, soothing sounds or manipulations, rent and 
exercise accurately adjusted to the needs of the system, 
presence or absence of noise, relief from sources of 
irritation. When certain areas of the brain are over- 
stimulated to exhaustion with wakefulness, the exer- 
cise of other parts, diverting the attention by pleasant 
conversation or fixing it upon a new subject, a short 
walk in the open air, gymnastics, an agreeable novel, 
a light supper, koumyss, matzoon, malt or cautiously 
used wine, beer, ale, porter, spirits, are expedients 
which are useful, some to one, and others to another 
wakeful person. Change of climate, scene and associa- 
tion, travelling, or, better, camp-life, especially in the 
mountains, a sea-voyage, or a wisely selected hydro- 
pathic establishment will often avail. Mountain air 
lias seemed to me best where there is increased vascular 
tension or diminished vaso-motor control, especially in 
those cases where sea-bathing, tonics, and alcohol dis- 
agree. The sea-level and a humid atmosphere, in my 
experience, have been useful for the anaemic, the ex- 
hausted, and those with cardiac disease. Often the most 
suitable climate is best determined by trying one after 
another. We have the authority of Marcus Aurelius 
for the statement that .iEsculapius prescribed horse- 
back exercise. The outside of a horse has been said 
to be the best thing for the inside of a man. Under 
any and all circumstances I endeavor to get such pa- 
tients into the open air, even when they are feeble, and 
into the air of the woods, or the sea, or the country, if 
possible. 

The application of cold to the head, heat to the feet 
or abdomen, of galvanism, faradism, dry cupping, the 
Paqueliu cautery, Chapman's ice-bags to the spine, or 
prolonged hot baths with or without cold affusion to 
the head, may be efficacious. Massage and the wet- 
pack are of the greatest value, and the treatment so 
properly identified with Dr. Weir Mitchell's name has 
made the only wise and efficient management possible 
for a large class, although, like all powerful remedies, 
capable of harm with unsuitable cases or in unskilled 
hands. 

In neurasthenia and in conditions of unstable equili- 
brium, nervous or psychical, particularly where alcohol 
and most medicines fail or have some disagreeable 
after-effect, personal influence may outweigh all else ; 
a teaspoonful of water taken with confidence becomes 
a hypnotic, and whatever develops or creates self-disci- 
pline and self-control in the patient is a remedy of no 
mean value. As Ruskin says, too, people think by in- 
fection, catching a passion like a cold. For these 
reasons the grotto of Lourdes, faith-cure, mind-cure, 
Christian science, spiritualism, hypnotism, have their 
devotees, and charlatanry may succeed where medical 
skill and experience fail. The physician's reputation 
or confidence in him, from experience, also go to make 
up no small part of the personal equation and the so- 
called moral treatment so long used with the insane 
has been, especially, in the hands of masters like Bell 
and Ray, an immense power. 

I am not fully prepared to say that hypnotic sugges- 
tion cannot be used to advantage in some cases of insom- 
nia. The evidence thus far inclines me to the opinion 
of Germain-See and Gilles de la Tourette, that the 
French Ministry of War is right in interdicting its use 



6 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 3, 1890. 



by the army surgeons on the soldiers, on the ground of 
its tendency to do harm. To many in the community 
there may be no corresponding or compensating harm, 
to others the evil is great, from such a degree and kind 
of suspension of the higher cerebral activities — from 
losing their grip, so to speak — and one cannot yet 
fairly estimate its general effect on the community. 

It is better, especially for people of the neuropathic 
temperament, to overdo, and, at times, to suffer some 
sleeplessness in consequence, than to sink into deeper 
and deeper inertia while striving to avoid every effort 
which brings discomfort with it, or after it, just as it 
is not always best to shut out every sound, even if dis- 
turbing to sleep. Many do best to bear a certain amount 
of wakefulness, as others must suffer pain, when our 
help avails much in giving strength and courage. 

Stimulating tonics, phosphoric acid, phosphates, hy- 
pophosphites, quinine, strychnine, iron may prove ser- 
viceable, but certain patients exhibit a marked intoler- 
ance of medicines and alcohol. 

- (To be continued.) 



EIGHT CASES OF LARGE, PULSATING ARTE- 
RIES ON THE POSTERIOR WALL OF THE 
PHARYNX. 1 

BY J. W. FAKLOW, M.D., BOSTON. 

In the Boston Medical and Surgical Journal of 
March 31, 1887, I reported five cases of visibly pul- 
sating arteries of the pharynx, which I presumed to 
be abnormally large ascending pharyngeal arteries. 
Since then I have seen seven other cases, and Or. 
F. I. Knight has kindly sent me the notes of a case 
in his own practice. 

Cask I. Mrs. M., forty-seven years of age. Some 
chronic pharyngitis. A large, pulsating vessel seen 
on the posterior pharyngeal wall, where the posterior 
pillar of the fauces of the left side joins the pharynx. 
The vessel had an oblique direction. 

Case II. Mrs. D., thirty-five years of age. Phar- 
yngeal membrane thin and atrophic. A large pul- 
sating vessel on the right side of the pharynx. 

Cask III. Mrs. C, fifty-one years of age. A 
large, pulsating vessel ou the left side of the pharynx. 

Cask IV. Mrs. W., thirty-eight years of age. 
Dry throat for two years. A pulsating vessel on 
each side of the pharynx, about half way between the 
uvula and the sides of the pharynx. The pulsation 
seemed not quite as strong as in the radial of the 
same patient. 

Case V. Mr. M., forty-eight years of age. 
Pharyngeal membrane thin. A good-sized pulsating 
vessel on the right side of the pharynx. Tins is the 
only instance I have seen in a male. 

Cask VI. Girl, fourteen years of age, sent to me 
by Dr. E. D. Spear. There was marked hypertrophy 
of the glandular tissue of the pharynx and vault and 
a distinctly pulsating vessel was seen on the right 
side. Dr. Spear had wisely congratulated himself on 
having noticed this vessel, otherwise, a removal of the 
adenoid tissue might have given rise to an uncomforta- 
ble haemorrhage. 

Case VII. Mary F., aged seventeen years. 
Atrophic pharyngitis. A pulsating artery on the ex- 
treme right side of the pharynx. 

I Read before the Boston Society for Medical Observation, May 
6, 1 



Case VIII. Lady, sixty-eight years of age, was 
the case seen by Dr. Knight. In the pharynx he 
observed the marked pulsation of two arteries, one on 
each side and approaching to within about one-quarter 
of an inch of each other. The right was decidedly 
the larger. 

In the British Medical Journal of September 17, 
1887, Dr. E. Creswell Baber gave an account of a 
case that he had seen, where there was a pulsating 
artery of the pharynx. 

It has seemed strange to me that so large a number 
of such cases should come to my notice. Possibly I 
have been, more than usual, on the look-out for them. 
I am inclined to think, however, that a thorough in- 
spection of ihe sides of the pharynx will bring to 
light a greater number of instances than have been 
hitherto reported. 



REPORT ON MEDICAL CHEMISTRY. 

BY WILLIAM B. HILLS, M.D. 

RECOGNITION OF BLOOD IN MEDICO-LEGAL INVES- 
TIGATIONS. 

For the extraction of blood-stains, Klein 1 recom- 
mends water saturated with carbon dioxide (Struve's 
process) as giving the best results. The stained spot 
is cut out, placed in a test-tube with two to three cubic 
centimetres of distilled water, and treated with a slow 
stream of carbon dioxide. Stains which are only a 
few hours old are usually completely extracted in 
five to ten minutes ; those up to two weeks old require 
fifteen to twenty minutes; those up to one month, 
about thirty minutes and those six to eight weeks old, 
from thirty minutes to one hour. Whitish or yellowish 
masses of fibrin are left unaffected. The clear, yel- 
lowish or brownish colored solution thus obtained is 
examined spectroscopically. In the case of stains 
extracted immediately after drying, the two absorption- 
bauds of oxyhemoglobin in the yellow and green por- 
tions of the spectrum are alone visible. If the spec- 
trum is shaded up to the red, the methsemoglobin 
band in the red is easily recognized. The intensity of 
the absorption-baud in the red increases with the age 
of the stain, and in stains fourteen days to one month 
old it is nearly as intense as the bands in the yellow. 
Stains five or six months old give solutions in which 
the band in the red is, at times, the only one visible ; and 
this was always the case in stains six to eight months 
old. Such old stains, after treatment with carbonic 
acid water for some hours, still leave behind a brown- 
ish-colored residue which, freed from adhering fluid by 
means of blotting-paper, gives up to glacial acetic acid 
or to ammonia after about ten minutes treatment a 
brown coloring matter whose acid solution iu thick 
layers shows plainly the absorption-band of acid hsem- 
atin. Both the ammouiacal and acetic acid solutions, 
when treated with ammonium sulphide aud twenty per 
cent, soda solution in slight excess, give the spectrum 
of reduced hsematin. 

Solutions of old blood-stains in carbonic-acid water, 
which have a reddish-brown color and show the 
methscmoglobin band in the red, are immediately 
changed by treatment with an aqueous solution of 
hydrocyanic acid (1-2 drops of a 1-1,000 solution, or 
12-15 drops of a 1-10,000 solution). The solution 

1 Zeitsehrift l'iir Analytischo Cheinie, 1889, page 389. Inaugural 
Dissertation, Dorpat, 1889. 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



7 



lias a reddish tinge and on spectroscopic examination 
only tin- hands in the yellow and green are visible; the 
methemoglobin band having disappeared. In place 
of this is a faint shading of the spectrum between the 
positions of the two oxyhemoglobin bands. Solutions 
of fresh blood-stains are apparently unchanged by 
hydrocyanic acid. The action of hydrocyanic acid 
possibly affords a means of determining the age of a 
given stain. For this purpose, the relative intensity 
of the absorption-bands in the red and green is deter- 
mined ; the hand in the red is then obliterated by the 
action of hydrocyanic acid ; the solution is then exam- 
ined in a layer so thick that the violet end of the 
spectrum is shaded, when a conclusion may, perhaps, 
be drawn, in regard to the amount of unchanged oxy- 
hemoglobin, from the intensity of the bands in the 
yellow and green portions of the spectrum. Solutions 
in carbonic-acid water which show the absorption-bands 
of oxyhemoglobin give, on careful treatment with 
ammonium sulphide, the spectrum of reduced hemo- 
globin. If this solution is shaken with air the oxy- 
hemoglobin bands again appear. Finally, if a few 
drops of soda solution are added, the spectrum of 
reduced hematiu is obtained. 

If the stain cannot be removed by scraping, one 
can, after the spectroscopic examination, precipitate a 
small portion of the carbonic-acid solution with suit- 
able reagents ; for example, chloral hydrate, zinc 
acetate or tannin, and employ the precipitate for the 
production of hemin crystals. The author has made 
a special investigation of the process recommended by 
Ferry de la Bellone. 2 The carbonic-acid solutions 
gave immediately, upon the addition of chloral solu- 
tion, a rose-colored turbidity and later a similar rose- 
colored precipitate, which settled completely after some 
hours. A drop of this precipitate gently warmed on 
a glass slide furnished a coagulum in which, after treat- 
ment with fuchsin and acetic acid, numerous blood- 
corpuscles were detected on microscopic examination. 
The test for hemin crystals was equally satisfactory. 
A small quantity of the precipitate dissolved in 
ammonia and treated with a few drops of a solution of 
ferrous sulphate and tartaric acid gave a solution which 
exhibited plainly the absorption-band of reduced hema- 
tiu. An acetic acid solution of the precipitate furnished 
an equally satisfactory absorption-band of hematin. 
The chloral precipitate dried over sulphuric acid in a 
dessicator and kept for six months, furnished, on proper 
treatment, hemin crystals and the spectra of hematiu 
and acid hematiu as satisfactorily as did the original 
moist precipitate. The precipitate obtained by the 
addition of zinc acetate to a carbonic-acid solution of 
blood-stains furnished, on proper treatment, the spec- 
trum of hematin in acid solution and of reduced 
hematin ; but, did not, as a rule, afford hemin crystals. 

If the fibrine left after extraction with carbonic-acid 
water is submitted to the action of water saturated with 
carbon dioxide for twenty to twenty-four hours and the 
residue is then examined microscopically, it is pos- 
sible at times, especially if the blood is dried in a thick 
layer and not on a porous surface, to recognize the 
blood-corpuscles, normal in shape and size. These 
could be satisfactorily measured after they were treated 
for ten to twenty minutes with a one or two per cent, 
solution of perosmic acid, or, after they were colored 
with an aqueous fuchsin solution. An excess of the 
fuchsin solution can be removed by washing with water 

2 Journal, April 4, 1889, page 337. 



containing carbonic acid. The diameter of blood-cor- 
puscles from stains varied after this treatment, in human 
blood between 0.00748 and 0.0078 mm., in the blood 
of the ox between 0.00592 and 0.00624 mm. 

In the case of stains more than six to eight months 
old from which carbonic acid fails to remove the color- 
ing matter, other solvents may be employed ; for ex- 
ample, dilute soda solution, acetic acid, etc. 

The author describes experiments in which the fore- 
going process with unimportant variations was em- 
ployed. In one of them some coarse sand was mixed 
with live per cent, of blood and examined ten years 
later with satisfactory results. 

SUGAR AND OTHER REDUCING SUBSTANCES IN URINE. 

The most important substance that reduces an alka- 
line solution of copper oxide, and that is apt, therefore, 
to be mistaken for sugar in urine, is glycuronic acid. 
This compound is the one which makes its appearance 
in the urine after the administration of chloral hydrate 
and croton chloral and which has been described as 
urochloralic acid and uronitrotoluol. It also appears 
iu the urine after the ingestion of brom-benzol, nitro- 
benzol, phenetol and some of the derivatives of quin- 
ine, benzol, indol, morphine and chloroform. 

H. H. Ashdown, M.D., has investigated a large 
number of specimens of urine, iu order to trace as far 
as possible, the presence of glycuronic acid and to dif- 
ferentiate it from glucose, and now publishes his results, 
together with a description of glycuronic acid and the 
method of obtaining it from urine. 8 

When pure this body appears in white amorphous 
granules; but in the state of anhydride, it forms fine, 
colorless acicular crystals. It is very readily soluble 
in water, not so readily in absolute alcohol, and 
scarcelj' at all in ether. Solutions of the aeid are 
very readily decomposed, but they are much more 
stable in an acid than in an alkaline medium. In the 
urine it appears in combination with urea, but it is 
difficult to say whether uroglycuronic acid, or glycu- 
ronate of urea best represent its relation to urea ; 
probably the former. It forms more stable com- 
pounds with barium and with lead. It holds the 
oxide of copper in solution in the presence of an 
alkali, and reduces it, throwing down the suboxide 
upon boiling, either in Trommer's or Fehling's test; a 
similar reduction occurs with the oxides of bismuth, 
mercury and silver. When pure it rotates the ray of 
polarized light to the right 35° ; but many of its com- 
binations rotate the ray to the left. It does not fer- 
ment in the presence of yeast, and thus markedly 
differs from glucose. 

The best method to obtain this acid from the urine 
is that recommended by Schmiedeberg and Mayer. A 
large quantity of urine is evaporated to a syrup, and 
then digested at a gentle heat over a water-bath with 
a considerable excess of damp barium hydrate. It is 
then extracted with absolute alcohol which leaves the 
acid undissolved together with a number of other 
urinary constituents. The residue is treated with a 
large quantity of water and filtered ; barium hydrate 
is added to the nitrate, which is again filtered and 
evaporated over a water-bath. There is thus obtained 
an amorphous, spongy barium compound, which is 
washed upon the filter with water, and decomposed by- 
means of sulphuric acid, again dissolved in water, and 
evaporated in vacuo over sulphuric acid, when crys- 

3 The British Medical Journal, January H5, 1890, (page 169. 



8 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 3, 1890. 



tals of the anhydride will be obtained. This method 
is not sufficiently accurate to allow of any valuable 
quantitative results. For definite recognition it is 
absolutely necessary to obtain the compound pure. 
The polariscope, unless used with pure solutions of 
the acid or with solutions of known combinations, is 
apt to mislead, since some of its combinations rotate 
the ray to the left, and others to the right ; and if 
glucose be also present very erroneous conclusions may 
be arrived at. The best method of differentiating this 
acid from glucose is the fermentation test with yeast. 

Ashdowu's investigations show that the urine se- 
creted after the administration of morphine and of 
chloroform, contains, not sugar, but glycuronic acid. 
These results confirm previous investigations of Meyer. 
The so-called glycosuria of curare-poisoning does not 
depend upon the presence of sugar ; for there is no 
fermentation with yeast. The quantity of urine ob- 
tainable in these experiments is so small, however, that 
it is not possible to separate out glycuronic acid. The 
author has never found any reducing substance in the 
urine after the administration of ether. After seciiou 
of the renal nerves, a paralytic secretion occurs; this 
contains a reducing substance which was found to be 
glycuronic acid. The quantity is never large, though 
distinctly marked. The author reports one case in 
which this reducing substance was excreted in large 
quantity. The man in whom this occurred enjoys per- 
fect health, and does not suffer from any of the symp- 
toms of diabetes. He however, passes daily very 
large quantities of glycuronic acid in a urine which is 
not increased in quantity or density. 

Gaube 4 has examined a large number of urines with 
regard to their reducing constituents, and states that 
in one case, that of an emaciated child, the reducing 
substance was aldehyde. 

Professor Huppert, in a private communication to 
Robert Kirk, 6 regards the uroleucic acid previously de- 
scribed by the latter 6 in the urine in cases of alcapto- 
nuria as a homologue of gallic acid and probably 
pyrogallol-propionic acid, or at least a trihydroxy phenyl- 
propionic acid. It does not give the genuine Millou's 
reaction, and therefore contains either no hydroxyl 
group in the benzine nucleus, or more than one ; it is 
optically inactive, and therefore contains no asym- 
metrical carbon-atom. 

Uroleucic acid was found to have considerable anti- 
septic power. It is entirely absent in normal urine. 
The substance previously described as uroxanthic acid, 
which accompanies uroleucic acid in these peculiar 
urines, has been more fully investigated, and found to 
consist simply of uroleucic acid mixed with hippuric 
acid as an impurity. 

According to Morner, 7 the urine of persons taking 
acetanelide (autifebriu) reduces alkaline solutions of 
cupric hydrate and is strongly laevorotatory. This is 
due probably to a derivative of glycuronic acid. 
Chittenden 8 finds that glycosuria is a very constant 
and characteristic symptom in poisoning by the salts 
of uranium. 

In the estimation of sugar by Fehling's solution, 
Causse 9 suggests the addition of 4 c.c. of a five per 

* Journal of the Medical Society, Loudon, February, 1890, page 1»8, 
from Oompt. Kend. Soc. Biol. (9) 1, 388. 

6 Journal of the Chemical Society, Loudon, February, 1890, page 
188, from the liritish Medical Journal, 2, 1889, page 1149. 

• This Journal, April 4, 1HM1, page 336. 

7 Zeils. Ph>sioi. Chem., 13, lj — 2.'). 

» Studies from the Lab. Physiol. Chem., Yale University, 3, page 1. 
' Journal of the Chemical Society, London, October, 18fc'J, page 1036. 



cent, solution of potassium ferrocyanide, and 20 c.c. 
of water to each 10 c.c. of Fehling's solution em- 
ployed. On ruuning in the sugar solution to the boil- 
ing mixture, the potassium ferrocyanide dissolves the 
cuprous oxide as quickly as it is precipitated, and 
forms a colorless solution, thus rendering the exact 
point of decoloration more easily seen and preventing 
bumping. Potassium ferrocyanide appears to be with- 
out action on hot or cold Fehling's solution. On cool- 
ing the liquid obtained after titration, it turns brown 
and deposits colorless crystals which the author intends 
to study. 

Crismer 10 recommends a 0.1 per cent, aqueous solu- 
tion of safranine as a reagent for the detection of sugar 
in the urine. One cubic centimetre of urine is heated 
to boiling with 5 c.c. of the reagent, and 2 c.c. of a 
ten per cent, sodium hydrate solution. If sugar is 
present, the safranine solution is decolorized. One 
milligramme of glucose in 1 c.c. of urine is sufficient 
to produce this effect. At the surface the color of 
the dye rapidly reappears, owing to reoxidation. 
Safranine is not reduced by uric acid, creatinine, chloral, 
chloroform, hydrogen-peroxide or hydoxylamine salts. 
Egg-albumen reduces it slowly, but completely. 

Josef Geyer 11 has studied the relations of glycuronic 
acid to phenylhydrazin in order to discover whether 
they form any compound resembling the phenylglu- 
cosazon, formed in the phenylhydrazin test for sugar. 12 
He finds that glycuronic acid and its sodium salt give, 
when treated in the manner recommended by Von 
Jaksch, yellow crystals which canuot be distinguished 
from those of phenylglucosazon. He also examined 
the urine in fourteen cases, and although all of these 
contained a substance resembling phenylglucosazon, 
and reacted positively with Trommer's test, only four 
responded to the fermentation test and rotated the ray 
of polarized light to the right. He concludes, there- 
fore, that the phenylhydraziu test is not a reliable one 
for sugar, and that the fermentatiou test and the test 
with the polariscope are the only reliable ones. 
Hirschl, however, has investigated this question and 
has reached a different conclusion. 13 He finds that 
urines free from any sugar usually give with the 
phenylhydrazin test an amorphous, yellowish-brown, 
or brown precipitate which cannot be mistaken for the 
phenylglucosazon crystals. This precipitate is appar- 
ently a compound of phenylhydrazin with glycuronic 
acid. Hirschl believes that sugar is certainly preseut 
if characteristic phenylglucosazon crystals are obtained. 

Torselliui 14 finds that the reaction for glucose with 
the copper and bismuth solutions is masked or pre- 
vented by the addition of a relatively large amount of 
saccharine ; but that the reduction is not prevented if 
one employs an excess of the reagent, or if the saccha- 
rine is first neutralized by sodium bicarbonate. Inas- 
much as saccharine does not modify the rotatory power 
of glucose, he advises the employment of the polar- 
iscope for the determination of sugar in the urines of 
patients who are taking saccharine. 

UROBILINUKIA. 

M. Hayem 16 considers that urobilinuria, when ha- 

111 Journal of the Chemical Society, London, April, 1889, page 416, 
and May 1889, page 552. 

n Wien. Med. Presse, 1889, page 1686. 
Journal, April 14, 1887, page 354. 

" Zeits. Physiol. Chem., 14, pages 377-389. 

'< Journal <le Pharmacie et de Cbimie, 1890, page 85. 

u Paris Correspondence, British Medical Journal, January 4, 
1890, page 43. 



Vol. CXXIir, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



9 



bitual, persisteut, and varying in degree, has a clear 
pathological significance, and is a valuable indication 
in forming an early diagnosis in diseases of the liver, 
lie regards urobilin as the cbaracteristic coloring mat- 
ter of hepatic incompetency, lie has observed uro- 
bilinuria in the following cases: (1) At the begin- 
ning of alcoholic cirrhosis. (2) In cardiac patients 
in whom the liver is not enlarged, it may be an indi- 
cation of incipient hepatic lesions. (3) In numerous 
acute affections when observed in alcoholic patients, 
sucb as typhoid fever. When a large proportion of 
urobilin is detected in this affection, reserve should be 
made with regard to the prognosis. (4) In newly 
delivered and nursing women. (5) In most forms of 
cachexia. Urobilin has a feeble coloring power, and 
is found in pale urine. The deep coloring of urine 
observed in certain affections (fever with perspiration, 
lassitude, overfatigue) is usually due to urochrome. 

THE URINE IN MELANURIA. 

R. v. Jaksch 16 describes the examination of the 
urine in two cases of melanuria. The cases were 
patients suffering from melanotic sarcoma ; in each 
case the urine contained a dark brown pigment. The 
following are the chief conclusions drawn : The most 
delicate reagent for detecting melanuria is a very 
dilute solution of ferric chloride ; this colors the urine 
black. In urine containing melanin or its chromogen 
(melanogen), prussian blue is formed when the urine 
is mixed with a nitro-prusside aud aqueous potash, 
and an acid added. The prussian blue reaction does 
not seem to depend on the presence of melanin or its 
precursor ; these substances do not give the reaction 
when they are separated from the urine ; it must, 
therefore, be due to some other substance excreted at 
the same time, and apparently some substance which 
is present in minute quantities, even in normal urine. 
The same substance is also abundant in urines which 
are rich in the indigo-yielding material. 

PRECIPITATION OF ALBUMINS BY INDIFFERENT 
BODIES. 

When urine is cloudy from the presence of bacteria, 
it is exceedingly difficult to obtain by filtration a 
liquid sufficiently clear to permit the detection of 
slight traces of albumin. Boymond 17 has made many 
experiments, hoping to discover some comparatively 
insoluble substance which may be employed as an 
aid to such filtration. He found that a perfectly 
clear and partially decolorized liquid may be obtained 
by simply shaking the urine for awhile with washed 
talc and then filtering ; but when urine, containing at 
the same time serine and globuline, were thus treated, 
the globuline was wholly removed, aud possibly a 
portion of the serine. He then extended his re- 
searches to other substances; washed animal char- 
coal, carbonate of lime, phosphate of lime, carbonate 
of magnesium, calcined magnesia, and subnitrate of 
bismuth. The result was the same, with this differ- 
ence, that subnitrate of bismuth removed completely 
both serine and globuline. Boymond proposes to 
continue his researches and extend them to other 
classes of "indifferent" substances. He calls atten- 
tion at this time, however, to a possible source of 
error, which is obvious, in treating urines in this man- 
ner as a preliminary to the test for albuminous sub- 

18 Journal of the Chemical Society, London, June, 188!), page 637, 
from Zeits. Physiol. Chem., 13, 385-394. 
17 Journal of Pharmacie at cle (Jhimie, 1889, page 481. 



stances, and suggests that urine, deprived of serine 
and globuline by means of subnitrate of bismuth, may 
serve for the determination of other constituents, and 
that talc, either alone or in conjunction with magne- 
sium sulphate, may be employed to precipitate globu- 
line ; affording at the same time a liquid perfectly 
clear, and more suitable for the detection of serine. 

IODOFORM. 

Choay and Gautrelat 18 find that, following the in- 
ternal administration of iodoform, only decomposition 
products of iodoform are found in the urine in those 
conditions which are atteuded with the excretion of 
an alkaline urine. On the other hand, in those condi- 
tions in which the process of oxidation taking place 
within the body is diminished, and in which an acid 
urine is excreted, iodoform is always present as such 
in the urine and can be removed by shaking the urine, 
with ether, which leaves characteristic iodoform crys- 
tals upon evaporation. 

POISONING BY TINNED CHERRIES. 

Arthur P. Luff, M.D., and G. H. Metcalfe 19 report 
four cases of tin-poisoning caused by tinned cherries. 
These cases are of special importance in that the 
form in which the tin was carried into solution was 
ascertained by analysis, and the amount of soluble tin 
salt present in the cherry juice was quantitatively 
determined. The patients were adult males. The 
symptoms of poisoning made their appearance in from 
one and a half to two hours. The local irritant symp- 
toms were abdominal pain, vomiting, diarrhoea, and 
in two of the cases a transient albuminuria. A feeble, 
irregular, and rapid pulse, together with marked col- 
lapse and cyanosis, were prominent symptoms in all 
the cases. As a result of appropriate treatment, all 
the patients were practically well in twenty-four hours. 
The cherry juice was strongly acid, and analysis 
showed that the acidity was due to malic acid with a 
small quantity of acid tartrate of potash. The juic<; 
contained tin in solution, a quantitative estimation of 
which, showed that each fluid ounce contained the 
equivalent of 1.9 grains of the higher oxide of tin, 
which would be equal to 3.2 grains of the malate of 
tin in each fluid ounce, or 60.4 grains in a pint. As 
far as could be estimated from accounts given by the 
patients of the number of cherries and the amount of 
juice they took, the symptoms must have been pro- 
duced by doses of the malate of tin varying from four 
to ten grains. 

SEPARATION OF STRYCHNINE FROM BRUCINE. 

J. E. Gerock 20 describes a method which is based 
ipon the fact that brucine is much more sensitive to 
the action of oxidizing agents than strychnine is, and 
that the products of the oxidation of the former alka- 
loid fail to give precipitates with the general reagents 
ior the alkaloids. Brucine undergoes this change 
when heated on the water-bath with nitric acid of 
specific gravity even below 1.06 ; while strychnine 
treated in a similar manner with nitric acid of specific 
gravity below 1.131 undergoes no change whatever. 

The following is the method of procedure recom- 
mended. The alkaloids are gently warmed and pre- 
cipitated from a neutral solution by means of picric 

« Chemisches Centralblatt, 1890, 1, 353, from Rep. d. Pharm., 1889, 
No. 11. 

'» The British Medical Journal, April 12, 1890, page 833. 
«» Archiv der Pharmacie, 1889, page 158. 



10 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 3, 1890. 



acid. After remaining for some time, the precipitated 
picrates are collected on a tared filter, washed with 
cold water till the washings become colorless, dried at 
105°, and weighed. The precipitate is transferred 
so far as is possible to a beaker, and those portions 
remaining on the filter-paper are repeatedly treated 
with nitric acid of specific gravity 1,056, previously 
warmed on the water-bath. This nitric acid is then 
transferred to the beaker which contains the rest of 
the precipitate, and the mixture is warmed on the 
water-bath for some time. The picrate of brucine is 
destroyed, while the picrate of strychnine is dissolved 
without undergoing chemical change. The solution 
is then exactly neutralized and a trace of acetic acid 
is added. After cooling the picrate of strychnine is 
transferred to the same filter as before, washed, dried, 
and weighed. From the difference in weight, the 
quantity of brucine can be calculated. 

STRYCHNINE— LIKE PTOMAINES. 

Jeserich 21 describes a ptomaine, which, like vera- 
trine, was colored red by hydrochloric acid, and gave 
no reaction on the further addition of concentrated 
sulphuric acid; but with potassium dichromate and 
sulphuric acid it gave a color-reaction resembling in 
every particular the reaction given by strychnine 
with the same reagent. It did not, however, cause 
tetanic convulsions when injected subcutaneously in a 
frog. 

White 22 has extracted from food by the Otto-Stas 
process an amorphous substance which gave, with sul- 
phuric acid and oxidizing agents, a purple color similar 
to that given in the strychnine test. The alkaloid 
was however tasteless. It was soluble in water, al- 
cohol and ether ; the aqueous solution was not alka- 
line ; it gave a precipitate with phosphomolybdic 
acid and with a solution of iodine iu potassium iodide, 
but no reaction with nitric acid or with ferric chloride. 

NICKEL. 

Rohde 23 has investigated the action of organic 
acids on nickel. Nickel utensils were exposed to 
the action of two and four per cent, solutions of lactic, 
acetic, citric, tartaric and butyric acids, both cold and 
hot. He concludes that the quantity of nickel dis- 
solved by these acids is altogether too minute to have 
any appreciable effect on the system, and that utensils 
made of nickel may be safely used for household pur- 
poses. The results of Rohde's researches corroborate 
those of Riche, which have already been noticed in 
these reports. 

DESTRUCTION OF ORGANIC MATTER IN TOXICOLOG- 
ICAL INVESTIGATIONS. 

F. Marino-Zucco 24 recommends covering the sub- 
stance with concentrated nitric acid and then passing 
nitrogen tetroxide into the mixture, heat being ap- 
plied when the liquid has become green. One kilo- 
gram of meat may be completely destroyed in half an 
hour, and the fat may be removed from the surface; 
after cooling. Experiments with definite quantities 
of arsenic, copper and zinc showed that the method is 
well suited for the purpose. 

21 Chemisches Centralblatt, October 12, 1889, page 617. 
** Ibid, October 19, 1889, page 691. 
2a Ibid, November 2 18x9, page 803. 

M Journal of the Chemical Society, London, Juno 1889, page (J53, 
from Cheinisches Centralblatt. 



l&eport£ of &orietie£. 

AMERICAN LARYNGOLOGICAL ASSOCIATION. 

The Twelfth Annual Congress of the American 
Laryngological Association convened in Baltimore, 
May 29th, 30th and 31st, in the lecture-room of the 
physical laboratory of Johns Hopkins University, 
Dr. John N. Mackenzie, of Baltimore, presided. 

The following Fellows responded to roll-call by the 
Secretary, Dr. C. H. Knight : Drs. Morris J. Asch, 
New York; F. H. Bosworth, New York; Wm. H. 
Daly, Pittsburgh; D. B. Delavan, New York; F. 
Donaldson, Baltimore; J. H. Hartman, Baltimore; 
F. W. Hinkle, Buffalo; Edgar Holden, Newark; E. 
F. Ingals, Chicago ; W. C. Jarvis, New York ; C. H. 
Knight, New York; S. W. Langmaid, Boston; A. 
W. MacCoy, Philadelphia ; J. N. Mackenzie, Balti- 
more; H. C. McSherry, Baltimore; J. C. Mulhall, St. 
Louis ; C. C. Rice, New York ; J. O. Roe, Rochester, 
N. Y. ; C. Seiler, Philadelphia; H. L. Swain, New 
Haven ; S. O. Vander Poel, New York ; B. F. West- 
brook, Brooklyn. 

One new member was elected, Dr. Jonathan Wright, 
of Brooklyn. The sessions were held twice daily, on 
the first two days ; the final session on Saturday morn- 
ing was held in the library of Johns Hopkins Hos- 
pital. 

the annual address. 

was delivered at the opening session Thursday morn- 
ing by the President, Dr. John N. Mackenzie, in 
which he alluded in complimentary terms to the 
scientific work done by the Fellows during the past 
year. No deaths among active Fellows had occurred 
during the year. The death of Voltolini, one of the 
pioneers of laryngology and a Corresponding Fellow 
of this Association, was referred to in appropriate 
terms. The great advances in laryngology made dur- 
ing the last few years, the increase in the number of 
those engaged in its practice, and the greater attention 
given to its teaching by medical schools, may make it 
advisable at a future meeting to enlarge the member- 
ship which now is limited to fifty, but the time had 
not yet arrived. A favorable mention was made of 
the Congress of American Physicians to be held next 
year in Washington, in which this Association will 
participate. The attention of Fellows was also called 
to the condition of the library, and they were invited 
to contribute their publications to this collection, in 
order to build up a valuable library, for which they 
have special opportunities. 

A SUGGESTION CONCERNING THE INTIMATE RELA- 
TIONSHIP BETWEEN BULBO-NUCLEAR DISEASE AND 
CERTAIN OBSCURE NEUROTIC CONDITIONS OF THE 
UPPER AIR-PASSAGES, 

was the title of a paper substituted by Dr. John N. 
Mackenzie, of Baltimore, for that which had been 
announced upon the programme. 

The reader stated that the reciprocal relationship 
between lesions of the central nervous apparatus and 
certain morbid phenomena exhibited in the upper re- 
spiratory tract, is a subject of surpassing interest, and 
one, strange to say, upon which comparatively little 
original work has been done. There has been too 
great a tendency for specialists to confine research 
within exact anatomical limits, and within too con- 
tracted a sphere of observation. The text-books give 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



11 



very little attention to this interesting class of cases, 
and what is given is in terms vague and indistinct, 
Functional aphonia, and the affections which Sir 
Morell Mackenzie has named "spasm of the tensors of 
the vocal cords," are illustrations. What do we know 
concerning the pathology of either of these ? They 
are expressions of some central trouble, but we know 
absolutely nothing of their primary cause or essential 
nature. The close nervous relations existing between 
the nasal chambers and the medulla and sympathetic 
nervous system, the lecturer had had occasion to refer 
to in previous communications, and would not further 
discuss. The present paper refers especially to bulbar 
lesions with symptoms of disorder in the upper air- 
passages. The case reported was that of a widow aged 
about forty, whose husband had been a drunkard, who 
had died about a year before she came under observa- 
tion. Her own habits had been always good ; she had 
not been infected by syphilis. She had been subjected 
to much mental strain and worry, and, although she 
had not been nervous previously, her friends had 
noticed that she became so after her husband's death. 
A short time subsequent to that event, while at house- 
work, her face became suddenly drawn to the left, 
especially the corner of the mouth. No difficulty in 
articulation occurred, and in three days the attack 
passed off. After an interval of perfect health, she 
was attacked by partial loss of power in her right 
hand, with loss of sensation ; there was tingling in the 
lower extremities without loss of power. This ting- 
ling seusation was also felt in the throat. She attribu- 
ted the attack to over-work ; she having carried wet 
clothes on her arm the day previous. These symp- 
toms gradually disappeared ; but a difficulty in articu- 
lation ensued, without aphasia; mouth again drawn to 
one side (the left). Several weeks after these symptoms 
had subsided, while sweeping her room, she was seized 
with foaming at the mouth, and puffing out of the 
cheeks, with tingling in the right hand. She could 
only mumble a few unintelligible words. No fall or 
convulsion. She walked up stairs to bed. Legs were 
swollen. About six weeks later she had slight dys- 
phagia, pain in the back of the neck and shooting 
pains in the hands. These symptoms also passed away. 
When she came under observation there was slowness 
in movement of the tongue ; it could not be lifted to 
the roof of the mouth, nor above the upper lip. The 
mouth was drawn at the angles; could not whistle nor 
kiss, nor blow out a candle at a greater distance than 
a foot from the mouth. Some difficulty in mastication, 
and in facial muscles, in movements of the muscles of 
expression. Complete paralysis of soft palate and 
uvula; reflex excitability there and in the pharynx 
notably diminished. Voice had nasal twang. Rhino- 
scopic examination negative. Saliva thick, tenacious ; 
difficulty in expectorating; requiring its removal with 
the finger or handkerchief. General muscular weak- 
ness, without paralysis. Temperature normal, respira- 
tion 30. Slight dyspnoea, much increased by exercise. 
Patient has hysterical spells of noisy crying and 
laughing. 

The patient was only seen once ; because she re- 
ceived an unfavorable prognosis, she never returned. 
Sufficient data, however, were obtained to demonstrate 
the bulbar-nuclear nature of the case, If in this class 
of disorders, neurologists and laryngologists could 
work together, more light would doubtless be thrown 
upon their pathology. 



Dr. Bosworth, considers the case as one of 
neuritis, especially of trifacial, and could not sec why 
it should be called one of bulbar disease. Moreover, 
if the latter, it would be necessary to determine what 
form ; whether a clot or a thrombus, or softening or a 
tumor. The diagnosis of bulbar disease is not enough. 

Dr. Delay AK: ever since Gottstein directed our 
attention to the throat symptoms of bulbar disease, 
there has been a tendency to refer all cases of nervous 
origin to a central lesion. Many of these cases are of 
bulbar disease, but it is possible for the central lesion 
to be other than bulbar. Indeed, cases have been re- 
ported where it was shown to have been cortical. 
While we may not at present be able to clinically 
differentiate these cases, yet it is very possible that we 
shall be able to do so in the future, by the combined 
work of neurologists and laryngologists. 

Dr. Bosworth, was not aware of any well-estab- 
lished case in which laryngeal paralysis was caused by 
a cortical lesion ; no case in which it was shown, by 
post-mortem, conclusively, that the cause was not in 
the bulb, but in the brain. Long before Gottstein, 
Hughlings Jackson had shown that in some cases of 
laryngeal paralysis the lesion is in the medulla. 

Dr. Del a van : It has been demonstrated that cats, 
dogs and monkeys have a cortical centre for the move- 
ments of the larynx, and it is probable that it exists 
also in man, though less developed perhaps. In some 
cases the bulbar lesion is demonstrated after death ; 
in others no such lesion can be found ; and the cause 
must lie in the hemispheres, more or less deeply in the 
cortex, as suggested by Ferrier. 

Dr. Bosworth : The psjchical centre must lie in 
the cortex. This can be conceded, but the motor centre 
for the larynx is in the bulb. This subject he had dis- 
cussed in a paper read at the last meeting of the 
Association, and had gone over the whole subject. 
There are but two forms of laryngeal paralysis. We 
have no other forms. 

Dr. Mackenzie: The case corresponds clinically 
with other cases of bulbar disease, and cannot be ex- 
plained on the grouud that it is a neuritis, especially of 
the trifacial, unless the nerve is distributed to the back 
of the neck and the lower extremities as well as to 
throat and larynx. He thought that the last speaker 
had misunderstood, or failed to hear the history of the 
case, and requested him to look over it carefully, and 
he would find the diagnosis of neuritis untenable. 

In the absence of the author, Dr. Jarvis was ap- 
pointed to read a paper by Dr. S. Solis Cohen, en- 
titled 

LOOK BEYOND THE NOSE. 

It was a plea for the broader view of the cause of 
diseases in the nasal chambers and their relation to 
general symptoms. Cases were reported showing 
mistakes in diagnosis, where headache and other 
symptoms, not relieved by operation, were promptly 
cured by general treatment. 

Dr. Roe : A headache, of course, always indicates 
that something abnormal is going on ; but when any 
man attempts to ascribe all headaches to one source, 
he also is abnormal. The causes are varied. Of two 
cases, both presenting affections of the nose or naso- 
pharynx, and treated precisely alike, one will be en- 
tirely relieved, the other will not be cured until he 
has appropriate constitutional treatment for the con- 
current disorder. He cited a case of his own. An 



12 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 3, 1890. 



operation had relieved a headache which had been 
troubling the patient for three or four years. There 
was marked pressure between the middle turbinated 
bone and the septum, which he had relieved. The 
facts of Dr. Cohen's paper go without the saying. 

Dr. Jarvis agreed with the last speaker, that we 
could not account for the fact that nasal obstruction is 
attended by nervous symptoms, such as headache in 
some persons and not in others. While reading Stan- 
ley's account of the expedition in Africa, he noticed 
that the blacks were quite unmindful of even serious 
wounds, and seemed to recover with little disturbance of 
health. This led him to formulate a theory that might 
explain the problem stated above. The ancestors of 
the blacks had been accustomed to being wounded, 
and to have their flesh cut or scratched in going 
through the undergrowth, so that after a number of 
generations the nervous system became less irritable. 
In civilized life, among the higher classes, protected 
as they are from physical injury, the nervous system 
becomes more susceptible. He has known a slight 
amount of nasal obstruction in a brain-worker to pro- 
duce a great deal of distress, headache, etc. The 
same lesion might be entirely unattended by nervous 
symptoms among the lower classes. The difference 
consists in the increased susceptibility of the nervous 
system to peripheral impressions. 

Dr. Bosworth : It seems like an indictment of 
the members to imply that they do not look beyond 
the nose. As competent specialists we all do look 
beyond the nose. 

The President endorsed the last remark, and 
thought that no discussion was required upon the 
paper. It appealed to the common sense of every 
person of intelligence. 

AN INSTRUMENT FOR REMOVING GLANDULAR 
HYPERTROPHIES FROM THE TONGUE. 

The presentation of instruments being in order, Dr. 
Roe exhibited a guillotine, made on the principle of 
the tonsillotome, for removing hypertrophied adenoid 
tissue from the dorsum of the tongue. 

Dr. Bosworth said that there was danger of cut- 
ting off the epiglottis in unskilful hands ; and several 
Fellows declared that they had never seen a case that 
would require the employment of such an instrument, 
and said that hypertrophied glandular tissue at the 
base of the tongue is a very rare condition. 

Dr. Roe said that the accident need not occur if 
ordinary care be employed in using the instrument. 

WIRE-LOOP CURETTE FOR REMOVING ADENOID 
NEW GROWTH FROM THE PHARYNX. 

Dr. Holden, of Newark, exhibited an instrument 
consisting of a flexible wire loop fixed in a handle, 
the loop being sharp upon its inner or concave side, dull 
upon its convex side. He had found it very useful in 
removing vegetations from the pharynx, acting very 
much like the finger nail. 

Dr. Delavan presented several instruments de- 
signed for the removal of adenoid hypertrophies or 
fibroids from the pharynx. One was a loop-shaped 
steel instrument, cutting on the inner side, the other 
being a sharp spoon, both being employed preliminary 
to using the forceps for the removal of these growths 
in young adults. 

In the opening of the afternoon session, Dr. Mor- 
ris J. Ascn, of New York, read a paper describing 



A NEW OPERATION FOR DEVIATION OF THE NASAL 
SEPTUM. 

He used (1) a peculiar shaped pair of forceps, or scis- 
sors, with short, curved blades, one of which is sharp 
and the other dull ; (2) a gouge ; (3) Adams's forceps ; 
and (4) a triangular splint of tin, cut to adapt itself 
to the cartilage of the section. In performing the 
operation, the patient is etherized, the adhesions be- 
tween the septum and turbinated body, when such ex- 
ist, are broken up by the curved gouge. The blunt 
edge of the scissors is inserted into the obstructed 
nostril and the cutting blade into the other. A cru- 
cial incision is then made as near as possible at right 
angles to the point of greatest convexity. The gouge 
is then inserted into the obstructed nostril. The 
segments made by the incision are pushed into the 
opposite one and the pressure continued until they are 
broken at their base and the resiliency of the septum 
destroyed. On this point depends the success of the 
operation, for unless the fracture of these segments is 
assured, the resiliency of the cartilage will not be 
overcome, and the operation will fail. The septum is 
then to be straightened with the Adams or other 
strong forceps and the haemorrhage checked before 
proceeding farther, which is usually accomplished by a 
spray of ice-water, though sometimes tamponing may be 
required. The nostril having been cleansed, the straight- 
ened septum is then held in position by the splint, 
previously wrapped with absorbent cotton, moistened 
in a solution of bichloride of mercury (1-5,000), and 
the nostril packed with gauze or absorbent cotton, 
moistened with the same. This should be done thor- 
oughly or hajmorrhage will follow. The splint is 
usually allowed to remain four days without being 
disturbed, and then removed ; and after cleansing and 
disinfecting the parts, the splint and tampon are then 
reapplied, the parts being straightened, if necessary, 
with the forceps. The treatment lasts from three to 
five weeks. If bony deviation is found to exist be- 
hind the cartilaginous one, it can be easily removed with 
the saw or electric trephine. Six cases were appended 
to the paper. 

Dr. Mulhall, of St. Louis, remarked that he 
came from the city of Dr. Steele, who was the in- 
ventor of the instrument for treating these cases, 
known as Steele's forceps, which he used in fifteen or 
twenty cases. Although not entirely pleased with it, 
he approved of the plan submitted by the lecturer, of 
restoring the parts with a single incision. Steele's 
forceps makes six cuts. He had often had persistent 
perforation at the centre of the crucial incision, and 
should give Dr. Asch's instrument a trial. 

Dr. Jarvis said that in order to prevent the per- 
foration, above mentioned, after operation, he had 
modified the forceps so that while the six incisions 
were made, an island in the centre was left untouched. 
With this he had never had perforation resulting. In 
order to keep the channel open he had discarded 
plugs, and resorted to an external nasal splint which 
he had devised some time ago. 

Dr. Ingals said that the principle of the instru- 
ment was not new. He had learned at college to 
make two parallel oblique incisions through the sep- 
tum, so as to make it movable and place in proper 
position. In nineteen out of twenty of these cases 
there is excess of tissue, and he advocated the removal 
of a triangular piece between the incisions, so as to 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



13 



permit the septum to fall into position. Where there 
is do hypertrophy, he would prefer to use a small 
trephine, making three or four perforations, and then 
the septum can readily be moved into position and 
kept there with some sort of splint. His own practice 
w as to pack the affected side with absorbent, aDtiseptic 
gauze, leaving the opposite nostril free. The dressing 
is changed in twenty-four hours by the patient and a 
douche used, before returning to the office. He then in- 
trudes a flattened tube of gutta percha, fitted to the 
nostril ; he prefers gutta percha to a soft rubber or 
ivory because it does not swell and cause pressure. 
The gutta percha may be wrapped around with gauze, 
if desired. It is easily moulded, when heated, to any 
shape. 

Dr. Roe said that where the deviation was limited 
to the cartilaginous septum, he was in the habit of di- 
viding it with a bistoury in the direction of greatest 
convexity, then forcing it into position with Adams's 
forceps, or a similar instrument, rather over-correcting 
the deformity. When the deviation exists also in the 
bone, he breaks it up with the forceps, and uses a 
gauze antiseptic plug in the affected side. In this way 
he almost always had good results. When an exos- 
tosis exists it should be removed. 

Dr. Bosworth complimented Dr. Asch upon bring- 
ing out such an ingenious instrument, which not only 
corrects a vertical displacement, but a lateral one as 
well. 

Dk. Mackenzie said that with Steele's instrument 
lie failed to cut through the septum. He had used a 
modification of these forceps made in Philadelphia, 
which had answered his purpose fully. He approved 
Dr. Roe's suggestion to remove a portion of the car- 
tilaginous septum when hypertrophied, in order to get 
a permanent result. His cases did not bear plugging 
of the nostril, and he considered it unnecessary. The 
septum cannot be kept in place by pressure. If anj'- 
thing of the kind is used, it should be cotton wet with 
glycerine or vaseline. With regard to the hard plug, 
he had seen unilateral convulsions caused by an ivory 
plug, this was repeated several times. He considered 
the after-treatment the most important. 

Dr. Langmaid said that it did not matter so much 
what means were used to break the septum, the object 
of treatment is to prevent the recurrence of the de- 
formity. He would emphasize the fact that after the 
operation the septum must remain in position of itself 
without pressure. He preferred a small black rubber 
nipple, wrapped with cotton, for a plug, and adapted 
to the shape and size of the nostril. He approved of 
Dr. Mulhall's suggestion, that patients should occa- 
sionally introduce a finger into the nose and push the 
septum over where there is a tendency to recurrence. 

Dr. Jarvis: With regard to the external nasal 
splint, although he had used it formerly in many cases, 
he had not used it lately. He now uses a new crown 
drill, with which he pulverizes the bony obstruction, 
guided by transfixion needles so as not to perforate 
the septum. In this way he secures enough room for 
the septum to fall into good position, and give good 
flow of air through the nostril. 

Dr. Bosworth considered it unjustifiable to re- 
move an organ of important functions simply for the 
purpose of admitting more air into the uose. 

Dr. Mulhall defended Steele's forceps against 
the charge that they would not go through the septum. 
He had not found this difficulty where there was no 



hypertrophy. Where there was this complication, he 
reduced the hypertrophy first. While there was a 
tendency to return after the operation, he had never 
seen it so decided as at first — never complete closure. 

Dr. Ingals: The resiliency of the septum must be 
gotten rid of before the operation is finished; after 
this, the treatment is very simple. He has had pa- 
tients wearing a plug for six weeks. Where there is 
great thickening, he advised running a small trephine 
through it several times, without perforation, until it 
can be easily pushed over to the other side. 

Dr. Mackenzie said, in reply to Dr. Mulhall, that 
he referred to deformed, and not thickened septa; 
Steele's forceps would not cut through ordinary thick 
paper, whereas those he referred to would cut six 
thicknesses of chamois skin. 

Dr. Daly said that he had not experienced any 
difficulty with Steele's forceps. He does not stop with 
one incision, but cuts the septum in several places. 
The object is to break up the cartilage, it is not neces- 
sary to perforate the septum. 

Dr. Asch, in closing the discussion, said that in the 
paper he had declared that the success of the opera- 
tion depends upon breaking down the resiliency of the 
septum ; this being done, the splint is introduced. If 
it is plugged lightly with cotton, there is no trouble 
whatever. With regard to his instrument, he had 
been led to it by his failure with Steele's. In Jarvis's 
plan, the resiliency of the cartilage is not destroyed, 
and the deformity will return. He had never had sep- 
tic symptoms after the use of the plug. 

Dr. Daly described his method of plugging the 
nostril with absorbent cotton, wrapped spirally with 
cotton thread, so that the entire plug could be easily 
removed. 

The President remarked that the whole discussion 
turned upon the necessity of overcoming the resiliency 
of the septum in order to secure a permanent result. 
This point he had already insisted upon in a paper 
read before the Association some seven years ago. 

Dr. Holden referred to a case of a young lady, 
upon whom repeated operations had been done without 
entirely overcoming the deformity. The septum in 
this case was then movable and crackled like parch- 
ment under the finger. The last operation with 
Steele's forceps, followed by ivory plug, had straight- 
ened the septum, but had left an ugly excrescence in 
the nostril, which he proposed to remove with the 
drill. 

Dr. Alexander W. MacCoy, of Philadelphia, 
presented a specimen, and read a report of 

A case of fibro-myxomatous tumor taken from 

THE NASO-PHARYNX OF A CHILD SIX YEARS OF 
AGE. 

This is the first case that had come under the lec- 
turer's attention in so young a child, although he had 
seen a polypus in a child under one year of age. 
Myxoma in the nasal chambers presupposes catarrhal 
inflammation, and this is why it is so rare in child- 
hood, because few have had chronic inflammation of 
sufficient duration to develop the pathological changes 
necessary for the growth of polypi. The tumor in 
this case filled the naso-pharyngeal region, but did not 
come below the soft palate. The attachment was 
about half an inch in diameter, the growth springing 
from the free surface of the vomer. It was removed 
by the galvauo-cautery snare ; the wire was passed 



14 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 3, 1890. 



through the nostril and around the base of the growth, 
and the pedicle cut through. There was trifling 
amount of haemorrhage. Recovery prompt and com- 
plete. The growth, upon microscopic examination, 
possessed the characters of a fibro-myxoma. 

The President said that he had previously pub- 
lished the notes of two cases of myxoma in children, 
and had referred to them in his article in Keating's 
" Cyclopaedia of Diseases of Children." They occurred 
in the same family, in a brother and sister, one four 
years of age, the other six. He removed both with 
the cold-wire snare. Morel 1 MacKenzie did not meet 
with a case under the age of sixteen years. Voltolini 
reported a case of polypus in a very young child ; 
such instances are apt to turn out to be simply hyper- 
trophies. 

Dr. Swaine had seen a case in a child eight years 
of age of fibro-myxoma, just before leaving Germany ; 
he did not know the outcome of it. 

Dr. Bosworth said that the tumor seemed to pre- 
sent the usual appearance of a fibro-myxoma ; being 
encapsulated. 

(To be continued.) 



AMERICAN ASSOCIATION OF GENITO-URIN- 
ARY SURGEONS. 1 

SECOND DAY. WEDNESDAY, JUNE 4TH. 

MORNING SESSION. 

A CASE OF SUCCESSFUL NEPHRECTOMY FOR 
ADENOMA. 

By Dr. E. L. Keyes, New York. 

A CASK OF SEVERE IlyEMATURIA : NEPHRECTOMY 
BY DR. MCBURNEY ; RECOVERY. 

By Dr. F. Tilden Brown, New York. 

Woman of twenty-six ; married ; three children ; 
previous health good. Came of gouty family ; three 
attacks of haematuria, first in March, 1888, second in 
August, 1888, and third in October, 1889. First two 
attacks recovered from in a week on the average. 
First attack diagnosed rupture of a renal vessel ; 
second attack diagnosed by a different physician as 
renal calculus ; third attack diagnosed by Dr. Brown 
as renal calculus, and nephrotomy was undertaken by 
Dr. McBurney for the removal of the calculus. 
Thorough exploration failed to reveal a calculus and 
the importance of immediate nephrectomy to check 
fatal hamiorrhage was apparent and at once performed. 
The operation was followed by a critical condition 
especially marked on the third day. Relief from hot 
air and steam bath in bed. Six days later miscarriage 
at about second month. Considerable loss of blood. 
Patient again prostrated, but slowly rallied and made 
complete recovery. Wound entirely healed by Decem- 
ber 15th. Operation, November 5th. The other 
kidney had been equal to all physiological require- 
ments. Histological examination of the entire speci- 
men by Dr. Delalield showed only chronic pyelitis 
attributed by him to the former presence of a calculus 
sometime since passed, probably ill the earlier clots of 
the first attack, but leaving an inflamed condition of 
the pelvis sufficient in his opinion and by clinical 
experience to account for this severe hamiaturia. It 
was on this account that the case was reported — 

1 Report of the Fourth Animal Meeting, at Altoona, Pa. Contin- 
ued from page CM of the last number of the Journal. 



this heretofore unrecognized variety of kidney lesion 
capable of such severe haematuria. The author would 
suggest " chronic pyelitis, with acute haemorrhagic 
exacerbations " as an appropriate name for this dis- 
ease. 

Dr. Belfield thought Dr. Brown's case unique, 
and the procedure undoubtedly correct, owing to the 
obscurity of diagnosis. 

Dr. A. T. C abot said he noticed in Dr. Brown's 
case that, in putting on the ligature, the ureter was 
included with the vessels. He cited a case in which 
he had adopted that plan, and although the stump 
was sufficiently long, and all possible care taken in 
tying, yet on separating the kidney from the vessels, 
there was a tremendous haemorrhage from the artery, 
which was with difficulty controlled. The patient 
lost a dangerous amount of blood, and lived only 
about twenty-four hours. Post-mortem examination 
showed no injury to any vessels, except the renal 
vessels and the haemorrhage was due to the drawing 
of the stump out of the ligature. 

Dr. F. Tilden Brown said he fully appreciated 
the warning of Dr. Cabot, but in his case the condi- 
tion of the patient was such that it rendered every 
moment of importance. 

Dr. Bryson had been accustomed to attach great 
importance to the specific gravity of the urine, as to 
the diagnosis and as to the favorable or unfavorable 
nature of the prognosis. 

Dr. Brown stated that the specific gravity was 
suggestive of a decidedly gouty condition ; but, on 
the other hand, there were no crystals of oxalate of 
lime or uric acid found which seemed rather a contra- 
dictory condition. After the operation the specific 
gravity fell, was low throughout recovery, and since 
recovery had been rather lower than normal. 

Dr. A. T. Cabot read a paper on 

A CASE OF CYSTITIS, WITH THE FORMATION OF A 
THICK EPIDERMAL SHEET IN THE BLADDER. 

Dr. J. W. White thought this case belonged in 
the class of cases which Guyon had described as 
" membranous cystitis." Guyon had reported a num- 
ber of cases in which even more extensive formation 
of membrane had occurred, and in which the patho- 
logical condition was practically the same. If one 
were quite sure of the diagnosis, and if the disease had 
reached the stage it had in Dr. Cabot's case he thought 
the suprapubic was undoubtedly the best method of 
procedure. We could hope for very little from wash- 
ing out the bladder or from internal remedies, although 
in certain of Guyon's cases large quantities of the 
membrane had been passed spontaneously with at 
least temporarily complete relief. 

Dr. Watson stated that he had had this patient 
under his care before Dr. Cabot took charge of the 
case, and that he was able from the urine to make a 
diagnosis of new growth but no new growth he knew 
anything about. If one knew there was this condition 
present it seemed to him the suprapubic operation was 
the only one one would care to try, because it was not 
like having an isolated tumor which could be reached 
through the perineum. One had to peel this off. It 
was very dense. 

Dr. Bryson said in those cases of exfoliative cysti- 
tis he had seen especially in women, there was more 
fibrinous admixture, more like the diphtheritic mem- 
brane than this seemed to be. 



Vol. CXXIII, No. l.J BOSTON MEDICAL AND SURGICAL JOURNAL. 



15 



Dr. A. T. Cabot presented specimens of the epi- 
dei i < i : 1 1 sheet, in this case. The sheet did not seem to 
resemble the fibrinous sheets lie understood to charac- 
terize the eases of Guyon. This was a thickened epi- 
dermal sheet and not a librinous sheet from the sur- 
face of the mucous membrane. The inflammatory 
element was very strong in Guyon's cases and not in 
this. 

A CASIO OF SUPRAPUBIC LITHOTOMY AND PROS- 
TATECTOMY, 

by Dr. -I. William White, Philadelphia, Pa. 

,]. S., sixty-eight; family history of tuberculosis; 
always a moderate drinker; recently intemperate; 
urinary symptoms six years ; catheter required at 
intervals for eight years. For four years unable to 
urinate without catheterization. Progressively in- 
creasing pain in hypogastrium, now (1889) excruciat- 
ing and felt also at end of penis and in rectum. Lost 
much flesh ; chronic bronchial cough. Eats and 
sleeps poorly. Urine scanty, loaded with pus and 
vesical debris, contains hyaline and grauular casts. 
Physical examination per rectum ; enlarged prostate 
both laterally and longitudinally, the finger being un- 
able to reach its upper limit. Bladder contains a soft 
phosphatic stone of medium size. Mitral murmur 
bronchial catarrh ; beginning consolidation at left 
apex. Operation, December 11, 1889. Linear inci- 
sion two and one-half inches long in linea alba just 
above the pubes. Stone crumbled under the touch of 
forceps and was removed by the finger and a scoop. 
The major portion of the projecting prostate removed 
by enucleation with the finger. Large drainage-tube 
inserted into the bladder and held in place. Outlook 
most favorable for three days. On the fourth mania- 
cal delirium, excessive restlesssness, wakefulness, 
jactitation, etc ; refused food, tore off dressings and 
had to be kept in bed by force. Tongue became dry 
and dark ; pulse increased in frequency ; no chill, 
sweating nor rise of temperature. Urine continued 
to flow through the wound which was irrigated daily 
with boric acid, listerine or phenol sodique. Patient 
passed into a stupor and died seven and a half days 
after operation. Autopsy: ureters distended to nearly 
size of wrist, kidneys almost completely disorganized 
containing multiple purulent collections, showing scars 
of previous abscesses and rendered almost useless by 
chronic nephritis. Tubercular changes in lungs. 

Dr. White offered some criticisms upon his course 
stating that in view of the kidney disease probably he 
should have been content with suprapubic lithotomy ; 
and that possibly the use of chloroform would have 
been better in this case ; also that after he had de- 
cided upon prostatectomy a less thorough operation 
might have been advisable. 

NOTES ON THE TECHNIQUE OF SUPRAPUBIC CYS- 
TOTOMY AND PROSTATECTOMY, 

by Dr. W. T. Belfield, Chicago. 

The reader summarized his method of procedure as 
follows : 

(1) Body upon inclined plane; pelvis eight or ten 
inches above shoulders. 

(2) Bladder moderately distended. 

(3) Rectum not distended. 

(4) Incision about one and one-half inches above 
upper border of symphysis and extends same distance 
below it. 



(.0) After division of deep fascia, linger inserted 
along posterior surface of symphysis until pubo pros- 
tatic ligaments reached, then pushes prevesical fat up- 
wards along anterior surface of bladder carrying peri- 
toneal fold, if present, with it. 

(6) Bladder attached to upper angle of wound by 
suture preferably through muscular coat only ; chrome 
catgut suture then inserted so as to make a subsequent 
quilt suture. Incision in bladder is close to symphysis. 

(7) After necessary intravesical manipulation the 
boutonniere is made. Tube one-half inch in diameter 
with two large lateral openings introduced over large 
uterine sound to the most dependent portion of the 
bladder and lixed by stitching through skin. 

(8) Bladder wound closed by the quilt suture already 
inserted and by several additional interrupted sutures. 
Retro-pubic space irrigated. Iodoform gauze inserted ; 
wound closed and dressed aseptically. 

A NEW M FANS FOR THE REMOVAL OF INTRAVESI- 
CAL GROWTHS THROUGH A SUPRAPUBIC CT8TO- 
TOM Y, 

by Dr. F. S. Watson, Boston. 

REMOVAL OF THE THIRL) LOBE OF THE PROSTATE, 
WITH COMPLETE RESTORATION OF THE FUNCTIONS 
OF THE BLADDER, 

by Dr. F. N. Otis, New York. 

O. P. B., came under observation, October, 1889, 
with a history of frequent urination dating back ten 
years. In early youth a slight urethritis. Two years 
ago marked diminution of size of stream of urine, and 
pain in urination. On examination, stricture found, 
to which his urinary difficulty was solely attributed. 
Internal urethrotomy. More easy flow of urine, but 
no relief to symptoms. Urine became purulent ; pain 
after urination increased ; and after some months 
severe spasms, referred to neck of bladder. Examina- 
tion discovered a vesical calculus. Litholapaxy, Octo- 
ber, 1888. Relief temporary. October 1889, patient 
debilitated ; urine ammoniacal, loaded with pus and 
mucus. Retention. Examination failed to recognize 
any prostatic enlargement or to detect any stone or 
pathological change in the bladder. No kidney ele- 
ments in urine. With the cystoscope a dark irregular 
spot about the size of a dime was seen on the left side 
of the bas fond. Slight induration recognized with 
end of cystoscope. This appearance was observed in 
subsequent examinations, and taken in connection with 
persistence of symptoms, seemed to warrant an ex- 
ploratory operation. Operation, November 22d. A 
well marked enlargement of the third lobe of prostate 
recognized. The suspected points in the bas fond 
proved to be a vesical calculus which evidently had 
been encysted. This was removed. The question of 
removal of the enlarged third lobe was decided in the 
negative owing to the condition of the patient and the 
fact that he was passing a large amount of urine of 
low specific gravity. Recovery from operation satis- 
factory. Symptoms, however, soon returned. In 
January, 1890, the enlarged median lobe removed 
through a perineal section. The first step in the 
operation consisted of a suprapubic section, through 
which the bladder was explored aud a phosphatic stone 
removed. An attack of subacute pleurisy rendered 
the condition of the patient critical and the convales- 
cence tedious. About April 1st, he returned home 
cured, with the exception of slight vesical catarrh. 



16 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 3, 1890. 



Dr. H. G. Mudd showed a 

FIBRO— MYOMA OF THE MALE PELVIS. 

Dr. J. W. White said he felt inclined to continue 
the use of the rectal bag, notwithstanding its dangers. 
It gave a firm basis of support behind and made easier 
the recognition of small growths. He believed some 
of the risks would be diminished by using a cyliudri- 
cally elongated bag. 

Dr. Post : He agreed with Dr. White that it was 
very difficult to know exactly in what cases of prosta- 
tic enlargement a portion of the prostate might be 
removed to give relief. There must be a number of 
cases in which we must be satisfied with some form of 
drainage, either through the perineum or over the 
pubes ; and there must be a pretty large number of 
cases in which it was impossible to isolate a distinct 
growth which could be removed as such and how much 
to remove in cases of concentric hypertrophy or where 
it was impossible to make out a distinct lobe he felt 
uncertain ; and it seemed to him it must require con- 
siderable experience yet to determine exactly the best 
course to pursue in each case. 

Dr. W. K. Otis said that perhaps a better way of 
operating in suprapubic cystotomy was not to fill the 
bladder until after the wound had been made down to 
the bladder in order to obviate any danger of bursting 
the bladder from the patient's movements while being 
etherized. Where there was a very small bladder that 
held only five or six ounces, it seemed to him better 
to open it on a sound, lifting the bladder up through 
the wound so that one might examine it more easily 
than one could otherwise a small contracted bladder 
with a small amount of water in it. 

Dr. Bangs said he had become conservative with 
regard to the performance of prostatectomy. In cases 
in which he had done suprapubic lithotomy and found 
a very seriously obstructing prostate which could be 
easily removed and without much danger to the blad- 
der, he had refrained, because he had observed that 
after the removal of a stone from a bladder which pre- 
viously had been unable to spontaneously evacuate its 
contents, the bladder had recovered its function, so 
that the amount of residual urine would be slight and 
perfectly clear and limpid. He thought elevation of 
the bladder by means of a moderately distended bag in 
the rectum did facilitate some steps in the operation 
and in old men especially, celerity of operation was 
very important. He had never found any especial 
advantage in draining the so-called prevesical space. 

Dr. Cabot thought there was great danger from 
the rectal bag, and that it was to be used with great 
care. There was this advantage in using it, that it 
brought into view the posterior wall of the bladder, 
where most of the tumors and morbid conditions were, 
and made much manipulation unnecessary. He thought 
the pear-shaped bag preferable to the sausage-shaped. 

Dr. Bryson thought we must rely upon the general 
health, no matter what the techniques of the operation, 
and the general health would be determined mainly by 
the condition of the kidneys. Suprapubic cystotomy in 
the young and vigorous was not, in his experience, at- 
tended witli bad results. Heart-failure he feared more 
than anything else in these cases. He thought the ob- 
servations of Dr. Belfield, in regard to the effect upon 
the arterial pressure of irritations about the rectum, 
vagina, etc., were of the highest importance. 

Dr. Belfield thought Dr. White need not censure 



himself for the fatal result in his case. He himself 
had lost a patient under precisely the same circum- 
stances, except that he had not removed a portion of 
the enlarged prostate. In his own case chloroform 
was used. As to the rectal bag, he meant that in the 
typical suprapubic cystotomy the bag was unnecessary, 
and should be omitted. There were cases in which 
the base of the bladder should be raised, and in those 
the bag was desirable. His conviction was that the 
advantage of suprapubic drainage, according to the 
method described by him, over what we used to call 
perineal drainage was enormous. Dr. Bangs had re- 
ferred to a case in which spontaneous urination oc- 
curred after simple drainage. Inasmuch as the cause 
of the condition was to be found in enlargement of 
the prostate, in his judgment it would be better to 
remove that cause, particularly as in the ordinary case 
it would not add materially to the danger of the opera- 
tion, and might prevent the return of the condition for 
which the operation was done. The condition of 
weakness, to which Dr. Bryson has referred, was un- 
questionably the chief factor to be feared. 

Dr. F. S. Watson said statistics showed that the 
palliative operations were quite as dangerous as the 
radical ones, and when one had opened the bladder 
he might just as well go on and take out the growth, 
unless the case presented some peculiar difficulty, such 
as extreme exhaustion, in which event one would se- 
cure drainage and subsequently complete the opera- 
tion. The device Dr. Otis mentioned of using a sound 
to lift up the bladder dated back to the early part of 
the century certainly. He was in accord with what 
Dr. Bryson had said in regard to the specific gravity 
of the urine. He thought the less the prevesical space 
was disturbed the better. Injection of both the rec- 
tum and the bladder, when it could be done, was, in 
his opinion, better than injection of the bladder alone. 
He did not think any drainage could be more thorough 
than that secured by the large-sized hard rubber tubes 
introduced by him two years ago. 

A CASE OF CONGENITAL MALFORMATION OF THE 
URETHRA, 

by Dr. A. W. Stein, New York. 

The malformation in this case was, so far as Dr. 
Stein knew, unique. It consisted of an abrupt diminu- 
tion of the canal about an inch anterior to the mem- 
branous portion. Urethra of normal calibre (33 F.) in 
front of the diaphragmatic obstruction ; but here the 
mucous membrane was folded upon itself toward the 
lumen of the canal, and the urethra was reduced to 
about fifteen millimeters in circumference, and remained 
uniformly diminished to the vesical orifice, a distance 
of about three inches. As there was frequent micturi- 
tion, and a history of gonorrhoea stricture was sus- 
pected, in exploring the urethra, the urethetome was 
first used, then the bougie a boule, and subsequently 
smaller instruments. All met decided obstruction 
about five inches from the meatus, giving the impres- 
sion that a very narrow stricture existed. Internal 
operations were abandoned, and external perineal ure- 
throtomy without a guide contemplated. He was suf- 
fering from phthisis pulmonalis, and operative inter- 
ference was deferred until he should become stronger. 
He died from asthenia in a few days. There was 
concentric hypertrophy of the walls of the bladder 
until its cavity was diminished to a capacity of about 
two ounces. 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



17 



Dk. .J. B. White mentioned a case of malformation 
of the urethra which had conic under his observation. 
The testes were bound down on each side of the peri- 
neum in such a manner as to represent, on first inspec- 
tion, the external genitals of the female. The penis 
was of the ordinary length and size for a child of two 
years, and there was no separation between the pre- 
puce and the glans penis; no phymosis ; no preputial 
opening, but the urethra opened just at the root of the 
penis between the two testes, and the penis gave much 
the appearance of an enlarged clitoris, and the other 
external genitals looked much like the external gen- 
itals of the female. 

Dr. Bryson stated, in connection with the general 
subject of stricture, that these were non-progressive 
cases. Whatever congenital malformation was there 
in the beginning remained the same throughout. 
(To be continued.) 



decent literature. 



Cyclopedia of the Diseases of Children, Medical and 
Surgical. Edited by John M. Keating, M.D. 
Volume III, 1371 pages. Philadelphia: J. B. 
Lippincott Co. 

The third volume of this work comes at a most op- 
portune time at the beginning of summer, containing 
as it does a large portion, — Part I, — devoted to the 
diseases of the digestive system, and one naturally 
turns at once to the article on "The Diarrhceal Dis- 
eases, Acute and Chronic." This important subject 
is discussed in a thoroughly scientific mauuer by L. 
Eintnett Holt in an article of one hundred pages, an 
article which, owing to the great strides made in tbis 
direction, differs widely from the chapters on this 
subject in text-books that have been published even a 
comparatively short time ago. The difficulty of clas- 
sifying the cases coming under this head is admitted 
to be very great, and Dr. Holt has endeavored to 
avoid this, and to clear up the confusion on the sub- 
ject, by a separate pathological and clinical classifica- 
tion. His attempt is a step in the right direction, and 
forms, for the present at least, a good working basis. 
Although it is well-known that the word "dysentery " 
is very often misused in children's diseases, still one is 
hardly prepared to find it entirely discarded. That 
diarrheal diseases depend upon bacteria as their prin- 
cipal exciting cause is thoroughly accepted by the 
writer, who bases his argument partly on the etiology 
of these diseases, partly on their clinical history and 
pathology, and partly on analogy. 

The chapter on pathological anatomy is formed 
almost entirely from a study of 109 autopsies, and is 
illustrated by excellent plates showing the intestinal 
lesions as seen with the naked eye and by means of 
microscopic sections. The chapters on treatment 
should be read with great care, as they are most ex- 
cellent ; but, as Dr. Holt says, "Those who consult 
these articles to find formulaj will be disappointed. . . . 
The routine use of certain complicated formulae be- 
cause some writer has lauded them as ' good for diar- 
rhoea,' cannot be too much condemned." The dietetic 
part of the treatment is of course very prominent, and 
the starvation plan for the first hours is especially 
recommended. The old-fashioned astringents are dis- 

at 



carded, and the limitations in the use of antiseptic 
drugs shown. 

A very interesting and suggestive chapter is pre- 
sented by Wm. I). Booker, on the " Intestinal Bacteria 
of Children," in which he says : " As far as the bio- 
logical characters of the bacteria in the diarrhceal 
stools of infants have been studied, it appears that not 
one specific kind, but many different kinds of bacteria 
are concerned, and their action is manifested more in 
the alteration of the food and intestinal contents, and 
in the production of injurious products, than in a 
direct irritation upon the intestinal wall." 

Earle, of Chicago, contributes a useful article on 
" Constipation," a subject which, notwithstanding its 
frequency, is not generally dwelt on in treatises on 
children's diseases. 

In a work so well illustrated we are surprised to 
find no plates or even figures of the intestinal worms, 
in the brief chapter devoted to the subject. 

Among the other valuable papers in Part I, are 
" Functional Disorders of the Stomach," by Pepper ; 
"Peritonitis," by Ashby ; "Congenital Abnormalities 
of the Intestine," by Wharton ; and some eighty-five 
pages on Diseases of the Liver, by Chapin, Musser 
and Hatfield. Musser gives a table of thirty-four 
cases of abscess of the liver in children. 

Part II, "Diseases of the Genito-urinary Organs," 
contains over two hundred pages of interesting matter 
by Tyson, Goodhart, Jacobi, Sturges, Keating and 
others, on the various divisions, many of the articles 
being profusely illustrated and exhaustively written. 
The paper on " Acute and Chronic Bright's Disease," 
by Goodhart, is particularly valuable, the writer point- 
ing out very clearly the peculiarities of this disease in 
children as distinguished from that in the adult. 

Griffith writes an extensive treatise on " Diseases 
of the Blood," unavoidably omitted from its proper 
place in Volume I. The methods for examination of 
the blood are thoroughly explained, and the article is 
illustrated by colored plates and by cuts. 

The last five hundred pages are devoted to " Sur- 
gery " and " Diseases of the Osseous System and 
Joints." A criticism might be made here that some 
of these articles, — notably that on " Wounds," by 
McCann, and "Amputations," by Hopkins, — might 
with advantage be much abbreviated by limiting them 
to the consideration of the subject as it concerns 
children alone. This criticism does not, of course, 
apply to such articles as those on " Club-Foot " and 
" Torticollis," by Bradford and Brackett ; on " Lat- 
eral and Functional Curvatures of the Spine," by 
Gibney ; on " Deformities of Bone," by Gerster ; on 
Pott's Disease," by Roberts ; and on " Mechanical 
Treatment of Deformities of Infantile Paralysis," by 
Brackett. It is impossible in this limited space even 
to mention all of these articles. They are carefully 
written and well illustrated, many of the illustrations 
being from photographs. 

This volume, like its predecessors, is thoroughly 
indexed, and is certainly a satisfactory work of refer- 
ence. C. w. T. 

An Experimental Study in the Domain of Hypnotism. 
By D. R. von Krafft-Ebing, Professor of Psy- 
chiatry and Nervous Diseases in the Royal Univer- 
sity of Graz, Austria. Translated from the German 
by Charles G. Craddock, M.D., Assistant Phy- 
sician Northern Michigan Asylum. Octavo, pp. xii, 



18 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 3, 1890. 



129. New York and Loudon: G. P. Putnam's 
Sous. 1889. 

This little monograph by one of the greatest alien- 
ists in Germany has already become classical ; and 
amid the mass of rubbish written on hypnotism by in- 
competent observers, it stands as one of the few ex- 
haustive scientific studies. It is with pleasure, there- 
fore, that we greet the work in a form accessible to 
the English reader. In October, 1887, Krafft-Ebing 
had the opportunity, which is so infrequent, of study- 
ing the manifestations of hypnotism in a peculiarly 
favorable subject. The patient was a young woman 
of twenty-nine, an hystero-epileptic of a pronouuced 
type, who had for many years been the victim of re- 
peated hypnotizatious. As a consequence, her con- 
sciousness was never entirely clear, but fluctuated be- 
tween complete and partial unconsciousness. She had 
typical hystero-epilepsy, right hemianesthesia and sex- 
ual perversion. In consequence of her unbalanced 
state, she had committed various acts, some of which 
had brought her into the hands of the police, who 
transferred her to the medical authorities at Graz. 
There, in her normal lucid state, she was found to pre- 
sent the ordinary picture of grand hysteria. It was 
very easy to hypnotize her; and in this state the only 
avenues of suggestion were the sensory and auditory, 
the cortex being in a state of great inhibition, to the 
exclusion of spontaneous apperception. Through sug- 
gestion in these channels, however, the experimenter 
could unlock any portion of the cortex desired, with 
unlimited power. By this means a therapeutic action 
was attempted, with some benefit. Unfortunately, 
however, an hystero-epileptic attack, or voluntary 
effort on the part of the patient, produced a third 
auto-hypnotic state. This state was found divisible 
into three, which could be experimentally produced, 
and in them, among other manifestations the patient 
unconsciously stole bright objects. Inhibition was less 
than in the second state ; but the attempt to carry out 
a post-hypnotic action commanded in this state, if it 
involved a state or a complicated action, threw the 
patient into a state of auto-hypnotism. These three 
spheres of consciousness never intersected. In the 
first the patient was an hystero-epileptic, with clear 
consciousness ; in the second she was in a state of 
great inhibition, but could be impelled to automatic 
action ; in the third she was a somnambulist, capable 
of spontaneous action within a limited sphere as a 
result of auto-suggestion or post-hypnotic suggestion 
by a third person, but depending on a dreamily deep- 
ened consciousness. In this state she became a thief, 
and could be made the involuntary instrument of crime. 

We must refer the reader to the original for the 
details of this study, the most valuable and thorough 
inquiry into hypnotic phenomena that has yet ap- 
peared. Krafft-Ebing recognizes the value of sugges- 
tion in the treatment of functional nervous affections, 
but the case shows most strikingly the dangers of hyp- 
notism in unskilled hands, — dangers which many en- 
thusiasts seem disposed to slight. p. c. k. 

— A doctor in Philadelphia has been arraigned on 
the charge (to which he pleaded guilty) of having sent 
a letter to a delinquent patient in an envelope on 
wrfich was printed, " Dead-Beat, Bad-Debt Collection 
Agency." The fine was one dollar and costs. One 
more case where the truth must not always be spoken ! 



THE BOSTON 

jtieDical ana ^urgtcal journal. 



THURSDAY, JULY 3, 1890. 



A Journal of Medicine, Surgery, and Allied Sciences, published at 
Boston, weekly, by the undersigned. 

Subscription Terms: $5.00 per year, in advance, postage paid, 
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eign countries belonging to the Postal Union. 

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283 Washington Street, Boston. 

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should be addressed to the undersigned. 

Remittances should be made by money-order , draft or registered 
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DAMRELL & TJPHAM, 
283 Washington Street, Boston, Mass. 



RECENT SPECULATIONS AS TO THE NATURE 
OF CANCER. THE ELECTROLYTIC TREAT- 
MENT OF CANCER. 

Dr. J. Inglis Parsons, of the Chelsea Hospital 
for Women, has published his views of the nature of 
cancer, and the results of the treatment by a new 
electrolytic process of several well-marked cases that 
were considered as unsuitable for operation. His 
paper has appeared in several of the British medical 
journals, and has been reprinted in Wood's Medical and 
Surgical Monographs for March,. 1890. Of the vari- 
ous hypotheses to explain the nature of cancer, that 
theory which has found its most elaborate expression 
in the Morton lecture of 1889 by Dr. John Marshall, 
although Dr. Parsons claims priority of statement, is 
that cancer is due to an escape of healthy cells from 
the control of the nervous system. Dr. Parsons asks 
whether it is not possible that all tumors are, in the 
first instance, composed of cells formed in the normal 
process of repair, but that, having escaped from the 
control of the nervous system, they take on an inde- 
pendent life, and continue to proliferate and develop 
without check, just as all living cells are capable of 
doing ad infinitum under favorable conditions ? The 
frequent association of cancer with a depressed condi- 
tion of the nervous system and with local causes of 
injury, is explained by this hypothesis. According to 
Dr. Gross's statistics, out of 907 cases of cancer of the 
breast, there had been antecedent inflammation in 20 
per cent., and a history of injury in 13 per cent. Dr. 
John Williams found microscopical evidence of the 
gradual transition from healthy tissue into cancer in a 
case described by him in the Harveiau lectures. 1 

Dr. John Marshall, in the lecture above alluded to, 2 
insists on the lack of demonstration that in the epithe- 
lioid cells of cancer there are any nerve fibres ; conse- 
quently, their growth and behavior are unregulated, 
disordered and anarchical. Even in plants there is 
" a fine, delicate, protoplasmic fibre " which seems to 
govern the evolution of the outgrowing cells of the 

1 Lancet, November 30, 1889, p. 1108. 
a Lancet, November 23, 1880. 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



19 



plant. In the auiinal, nerve filaments penetrate into 
all normal epithelial tissues ; " it has been, moreover, 
demonstrated that a nerve, a commanding thread, an 
electric cord, as it were, passes into each individual cell, 
and what can be assigned as a function to it, except 
that it is the governing cord, the co-ordinating fibre of 
its life? " 

Dr. Marshall does not believe " that in the pell-mell 
agglomeration which we see in a cancer, each cell has 
its own proper guiding fibre." In answer to the ques- 
tion how the nerve connection comes to be severed ? 
he thinks that it may be from the extreme rapidity of 
the cell growth. In the healthy formation of epithelial 
tissue, the nerve tissue would still remain in it; but in 
the overgrowth excited by some injury, "the cells 
break away from the nerves; they retain the power of 
multiplication within themselves, because each cell, 
like the cell of a minute infusorial creature, contains 
the quantity and kind of material which is necessary 
to build it up, but it does not retain the governing 
tissue with its power of control." 

We have not time to enter into the further explana- 
tions based on the supposed chemistry of the cancer- 
cell, which form an interesting part of Dr. Marshall's 
lecture. Dr. Parsons also insists on the severance of 
nerve connection, and on the consequent proliferation 
of the cancer-cells, resulting from their independent 
existence, "which enables them to overcome the 
healthy cells, since these, for want of sufficient stimu- 
lus, remain passive." But the malignant cells mul- 
tiply with such prodigality that they soon suffer in 
their nutrition, and their vitality is lowered; and this 
very fact causes them to perish more readily than the 
healthy tissues. 

Dr. Parsons has experimentally attempted the de- 
struction of cancerous growths with both the inter- 
rupted and the constant voltaic current. He has found 
the constant current worthless to check the growth of 
cancer, while from the interrupted galvanic current, 
some most gratifying results have been obtained. The 
modus operandi is as follows : The patient is anaes- 
thetized, the current is then passed through the tumor 
and all the tissues for some inches around it by means 
of fine insulated needles, so as not to injure the skin. 
A battery of seventy cells, with an electro-motive 
force of 105 volts, is used ; the intensity of the current 
to commence with is ten milliamperes, gradually in- 
creased to 600 milliamperes, and gradually flashed 
through the growth in every direction from fifty to 
one hundred times, according to circumstances. The 
pulse and respiration are carefully watched. The ef- 
fects produced by the action of the electricity consist 
in a cessation of growth, gradual disappearance of 
pain, some shrinking and hardening of the tumor and 
enlarged glands, followed by improved nutrition aud a 
better state of the general health. The growth, as a 
whole, does Dot disappear, but remains as an inert mass, 
composed, in all probability, of fibrous tissue alone. 

The advantages claimed for this method of treat- 
ment are as follows : 



(1) There is no destruction to the normal tissues of 
the body, and if recurrence should at any time occur, 
its progress can he immediately stopped, and the treat- 
ment repeated as many times as necessary. Life would 
by this means be prolonged indefinitely, provided that 
metastatic deposits had not occurred before the com- 
mencement of the treatment. 

(2) Patients are not obliged to keep their beds for 
more than a day or two, as a rule. They lose no 
blood, and are not generally any weaker. 

(3) The current can be passed through almost any 
part of the body, and thus arrest growths which could 
not by any possibility be otherwise treated. 

The above may be regarded as the latest phase of 
the question of the electrolytic treatment of cancers. 
It is for the electro-therapeutists to judge as to the 
merits of this method. It is notorious that constant 
currents of considerable intensity have failed to arrest 
or destroy cancerous growths, though often effectual 
iu the case of fibroid tumors. Dr. Parsons thinks that 
he has demonstrated that the interrupted voltaic cur- 
rents may, under careful management, be used with 
safety, while their destructive effect on the cancer-cells 
is considerable; to quote his own language: "the im- 
pact of a powerful current, when suddenly flashed 
through, causes death to those tumor-cells which lie in 
the nearest path between the poles where the lines of 
force are most concentrated, or else they are suffi- 
ciently injured to lead to their gradual atrophy." 



A WORD TO YOUNG PRACTITIONERS ON 
" CHANGING DOCTORS." 

It is not intended to give to young men just start- 
ing in practice any lengthy advice — of that they have 
probably received their full share, all they care for, 
aud more than they will heed; but there is one subject 
on which a word may not be amiss. 
• It is inevitable that they should see patients whom 
they would prefer to keep, leave them for some other 
practitioner. It is a common experience, and unavoid- 
able. In a large city it is a matter of little consequence : 
in a country town it is more serious, and often causes 
very bitter feelings. But no man ever gains anything 
by being angry over it. It is much better to recognize 
the fact that it must occasionally happen, and to accept 
it gracefully. If a family is determined to change, it 
has the right to do so. If the doctor is angry and 
shows it, he makes it impossible for them to return to 
him later if they should, at some future time, realize 
that the chauge was a mistake. 

The fact will remain that no one physician can ren- 
der satisfactory service to everybody. Human nature 
is too diverse in its various forms for any one practi- 
tioner to give universal satisfaction ; and it is well that 
it is so, or all practice would gravitate toward that one. 

Nothing that has been said is intended to lessen the 
efforts of every practitioner to act honestly by every 
case that falls into his hands, but simply to induce iu 



20 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 3, 1890. 



the minds of younger members of the profession a 
philosophical spirit which will prevent the loss of a de- 
sirable patient from destroying their peace of mind. 



MEDICAL NOTES. 

— Up to June 25th there had been a total of one 
hundred and ninety-six cases of cholera in Valencia, 
of which one hundred and thirteen proved fatal. Such 
violence of the disease shows that it is of a malignant 
type. 

— The bill providing for three separate boards of 
State medical examiners in New York State after 
September 1, 1891, to be appointed by the regents of 
the university — one board to represent the medical 
society of the State of New York ; one to represent 
the homeopathic medical society of the State of New 
York ; and one to represent the eclectic medical so- 
ciety of the State of New York — has been signed by 
Governor Hill, and is now the law of the State. 

— The Faculty of the Jefferson Medical College, 
Philadelphia, have contemplated the enlargement of 
their building for over two years. About one year 
ago they secured several properties fronting on Wal- 
nut Street, west of Tenth, for this purpose. It is now 
stated that the proposed improvements will be made 
within the next six months. The addition, when fin- 
ished, will be used for class-rooms, operating-rooms, 
clinics and library. 

— Medical students in London have been com- 
pelled to go through a course of four years' study, 
hospital attendance and lectures before being qualified 
to appear for the final examination. By an order of 
the General Medical Council of England, issued last 
month, the term of preparation has been extended to 
live years. 

The Raleigh, N. C, Chronicle is one paper which 
has an appreciation of the medical profession. Speak- 
ing of the late meeting of the State Society, it says : 
" There is no profession in the State that stands 
higher — and deservedly so — than the medical pro- 
fession. Learned, kind, sympathetic, benevolent, they 
are an honor to the commonwealth, and deserving of 
all the esteem and love that an affectionate and grate- 
ful people can show to the best product of their civil- 
ization." 

— The Medical News says that on May 26th the 
Bicetre, the great Parisian asylum for the insane wit- 
nessed the strange sight of a rebellion of its inmates. 
The rebellion was begun by a maniacal patient bursting 
the bars of his cell and then releasing forty others. 
They attacked and drove back their guards, and then 
proceeded to ransack the quarters of the keepers, after 
which they kept up the fight quite fiercely until the 
guards got access to the water-hose and turned it on 
them ; this frightened and cowed the rebels so that 
they retreated and were one by one returned to their 
cells. 



— A contemporary calls attention to the growth of 
the "naphtha habit" among the female employees of 
rubber factories. The inhalation of naphtha fumes 
produces a peculiarly agreeable inebriation. Naphtha 
is used to clean rubber ; and is kept in large boilers, 
to the valve of which the employees obtain access and 
breath the fumes. The habit was introduced from 
Germany, and is chiefly found in New England. 

— We clip the following sentences from Mr. Lawson 
Tait's recent address on " The Details of Abdominal 
Section," before the Cardiff Medical Society : " It is the 
nidus for germs that is to be feared, and not the germs 
themselves, and your every care should be to have 
nothing about that could serve as a soil for their growth 
and development. I use plain water, no kind of chem- 
ical compound. ... I never allow nurses to wear 
watches with second hands, but I give them a little 
sand-glass which runs for a minute, so that there is no 
margin for error. I take the temperature in centi- 
grade, so that the friends of the patient may not under- 
stand it." 

— It appears that in China the distinction between 
the physician and the surgeon is somewhat sharply 
drawn, as appears from the following story told by 
the writer : 

" An English tourist was riding a bicycle in Hong 
Kong, when he fell from his bicycle with such violence 
that one of the wire spokes was run into his shoulder, 
where it broke off and stuck fast. The man was 
removed to a house and a surgeon summoned. The 
surgeon first demanded his fee. After pocketing his 
money he broke off the protruding point of the spoke, 
leaving the other fragment imbedded in the sufferer's 
body. He then went away. The tourist was in 
intense agony, but the surgeon would not help him. 
Medical etiquette forbade. ' The case is for the phy- 
sician,' he said, ' as the wire is inside the body.' " 

— A curious fraud has been detected in Milwaukee, 
where a warrant was issued authorizing the arrest of 
Joseph A. Wilt, Dr. C. A. Jansen and Jim Lee, alias 
Gun Wa, on a complaint sworn out by a city detec- 
tive, charging them with conspiracy to defraud, ob- 
taining money under false pretenses, unlawful assump- 
tion of the title of " doctor," violation of the pharmacy 
statute and circulation of obscene literature. Gun 
Wa is an alleged Chinese physician and graduate of 
several Chinese medical colleges, who professes to 
cure all diseases known to man. Wilt is his manager 
and Dr. Jansen interpreter. Their office was estab- 
lished in July last and has done an enormous business. 
Wilt acted as manager and interpreter until March 
last, when the increase of business was such that it 
was found necessary to procure help and Dr. Jansen 
was brought on from Chicago to act as interpreter. 
An investigation was set afoot and it was found that 
the alleged doctor was a Chinese laundryman sent on 
from Denver by Frank L. Smith, head of the Gun 
Wa company, which has branches in Denver, Kansas 
City, Detroit, Indianapolis and Milwaukee, and that 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



21 



neither Wilt nor Janeen, who acted as interpreters, 
could speak a word of Chinese. Since opening the 
ollice here a year ago three Chinamen have played 
the part of Gun Wa. 

NEW ENGLAND. 

— A considerable number of cases of typhoid fever 
has recently appeared in Waterbury, Conn., and the 
Hoard of Health has forbidden the further use of the 
milk of a neighboring dairy, among the patrons of 
which a disproportionate prevalence of the disease is 
said to have occurred. 

ACUTE OEDEMA GLOTTIDIS AFTER POTAS- 
SIUM IODIDE. 

Casus of this nature are few in number, and one re- 
ported by Dr. Groenouw is quoted in the Practitioner, 
for June, from Therapeut. Monatschefte, No. 3, 1890. 
"A strong, healthy man, forty-three years of age, 
suffering from optic atrophy, and with the urine 
quite free from albumen and sugar, was treated with 
iodide of potassium, iu the form of a watery solution, 
in doses of seven to fifteen grains thrice daily. On the 
afternoon of the second day, when he had taken about 
forty grains of the salt, he complained of a feeling of 
rawness in the throat ; by the evening of the fourth 
day there was hoarseness, with pain on swallowing, 
localized in the right side of the larynx. These symp- 
toms, which were not by any means prominent, were 
not more pronounced on the evening of the sixth day, 
after the use of a little over three drachms of iodide. 
The same night, after two hours' quiet sleep, the pa- 
tient awoke, began to cough, and noticed suddenly, that 
although the expiration was free, the inspiration was 
difficult, and he felt as if a valve were in the throat. 
The difficulty lessened in the space of two hours, and 
he slept again, the dyspnoea having quite disappeared 
by next morning. In the afternoon, on examination, 
the right ventricular band was cedematous, as also the 
mucous membrane over the arytenoid cartilage and the 
ary epiglottic ligament. After an intermission of two 
days, the iodide was resumed ; and although the dose 
was a full one, no further symptoms of iodism appeared. 
In spite of the severity of the attack tolerance was 
established. The iodide of potassium given was ex- 
actly the same as other patients were using, and it is 
not likely that the symptoms were due to impurity of 
the drug. Groenouw observed a similar case two 
years ago in a woman of sixty-six, who was the subject 
of a moderately enlarged thyroid, but without difficulty 
of breathing, and was suffering from oculo-motor palsj' of 
one eye, for which iodide of potassium was prescribed 
in small doses. After seven grains, severe coryza and 
conjunctivitis, with great dyspnoea and loss of voice, 
came on. Examination showed marked pharyngeal 
catarrh and evident swelling and redness of the ventri- 
cular bands. Three days later, when the symptoms 
had subsided, four grains were given daily for three 
days ; but, on being increased to twice daily, there 
appeared — more or less every time — hoarseness, 
difficulty of swallowing and pain in the head. The 
drug was accordingly stopped for four days, and then 
the patient took about four grains daily, diluted with 



much water, the dose being gradually increased in the 
course of the next two weeks to fifteen grains a day. 
On attaining this amount, it had to be reduced on 
account of pain in the throat and general restlessness ; 
and seven days later it was discontinued altogether. 
Groenouw thinks the following conclusions may be 
drawn : After the administration of iodide of potassium, 
there occurs in certain rare cases great dyspnoea due 
to oedema of the glottis, sometimes so extreme as to 
demand rapid tracheotomy. D does not arise from 
long use or large doses — relatively small amounts 
hare hitherto induced it; and other symptoms of iodism, 
such as headache, are wanting. The action is local 
upon the larynx, not part of a general oedema. Ds 
cause is certainly the iodine, not the potassium, and it 
cannot be ascribed to any impurity. No local or gen- 
eral diseased state, for instance, cardiac or renal dis- 
ease, can be recognized ; and the cause must be looked 
for, rather in an iodiosyncrasy of the individual, 
although even this is not by any means absolute, as a 
complete tolerance may be established after a few days' 
pause." 

SOME CONSERVATIVE VIEWS OF HYPNOTISM. 

In the discussion on this subject, which has, of late, 
been carried on, there have not been wanting those 
who protest against the recognition of hypnotism as a 
therapeutic agency, particularly from its dangers if 
abused as it is so likely to be. The lawyers have been 
turning their attention to it and recognize that its pos- 
sibilities for crime are great. Among medical opinions 
we insert two, first that of Dr. E. C. Spitzka, the pres- 
ident of the American Neurological Association, who 
says : 

" 1 find it difficult to discuss the matter with patience. 
That the phenomena of hypnotism exist and that they 
command the earnest investigation of scientific men 
there is no doubt. But I do not believe the time has 
come to use the method as a remedial agent. We 
don't know enough about it. I am sorry to say I can- 
not draw a sharp line between some of the phenomena 
of hypnotism and the ideas of the spiritualists and old- 
fashioned mesmerists. The charlatans who use the 
system to humbug the public are frauds who should be 
suppressed. Did you ever see a collection of photo- 
graphs of those people? The rogues' gallery would 
be a collection of gentlemen compared with them. And 
yet they undoubtedly have a mysterious power over 
certain persons. Animal magnetism won't account for 
it. I saw the other day the daughter of a New York 
physician, a delicate, beautiful young girl, completely 
hypnotized by one of the ugliest, most repulsive-look- 
ing Russians you ever saw." 

Again, Sir Andrew Clark says, in the Lancet: 
"The first thing that strikes me in connection with 
hypnotism is the confidence with which it is asserted 
that it has been proved beyond dispute to be so success- 
ful that it cannot drop. But 1 am old enough to 
remember that this was said in the time of mesmerism. 
Practically, mesmerism fell into desuetude fifteen years 
ago. Except in distant corners such a thing is scarcely 
heard of. Now, from some researches which have 
been conducted at Nancy and stimulated by the oppo- 
sition of the Salpetriere school, we have the subject 
once more brought before us, and we are told of the 
advent of a great and important practical truth. There- 
fore we are told that hypnotism has established itself 



22 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 3, 1890. 



for all good. I have no hesitation iu prophesying that 
before twenty-five years have passed it will be in the 
same position that it was twenty-five years ago." 



€orre£ponDence. 

LFrom our Special Correspondent.] 
PARIS LETTER. 
DR. PEAN. 

Paris, June 6, 1890. 

Mr. Editor : — ■ The subject of this note is about sixty 
years of age, and more than twenty years ago he obtained 
the world-wide reputation of being a skilful surgeon and 
a brilliant operator. Those who have visited the Hopital 
St. Louis, of which he is surgeon, have greatly appreciated 
his merits as an operative surgeon. He has often been 
compared to Fergusson for general surgery, and to Sir 
Spencer Wells and to Lawson Tait for abdominal surgery, 
in which branch he has excelled. Saturday is his day for 
operations at the hospital, when a great number of foreign 
surgeons may be met there. Every Saturday he performs, 
between 10 and 12 o'clock, five or six operations, among 
which are always several of considerable importance. 
He delivers, at the same time, clinical lectures on the 
cases on which he is about to operate. The scene in the 
operating theatre is striking and characteristic. He is a 
man of powerful build, with black hair and whiskers, his 
face shows intelligence and determination, and his whole 
appearance indicates a man of superior knowledge and 
great courage. While energetic in manner, he is cool 
and self-possessed. He is in the habit of describing 
always beforehand, as most French surgeons do, the lead- 
ing features of each case on which he is about to op- 
erate, and the precise method which he intends to adopt. 
While operating, he describes each modification of his 
methods which the circumstances call for, and clearly 
demonstrates not only his manual of proceeding at each 
stage, but the reasons which dictated it, and the changes 
which he introduces to suit the peculiarities of the case as 
it develops itself under the knife. 

What attracts the attention of visitors is the display of 
numerous instruments, and the number of large and small 
haemostatic forceps, which he has adopted in preference 
to any other method of arresting haemorrhage. He has for 
a long time almost completely abandoned ligatures, relying 
on the use of preventive compression by small and large 
haemostatic forceps, of which he makes the freest use. By 
this means he succeeds in greatly abridging the time occu- 
pied in operation, and in arresting the flow of blood, which 
is otherwise apt to obscure the view of the parts in course 
of operation both from the surgeon and the spectator. He 
claims that the free use of his haemostatic forceps gives 
much greater certainty to the proceedings of the operator. 
Dr. Pean performs more than five hundred operations 
every year in this hospital, exclusive of the operations per- 
formed by him in private " maisons de sonic" with very 
encouraging results. Those for the past year, for example, 
have been so successful that he has not had one single 
death due directly to the operation. 

As a general surgeon J)r. l'ean may find his equal 
among the younger surgeons of the day, but for abdom- 
inal surgery, and particularly ovariotomy, he has cer- 
tainly not been surpassed. Among the most important 
of his modifications of ordinary operative proceedings is 
that which he describes as "le morcellement," or removal 
of tumors in portions, by proceeding from the centre to 
the outer circumference. Piecemeal enucleation, " morcelle- 
ment of tumors," and compression of vessels by haemostatic 
forceps left in situ, combine considerably to abridge the 
time occupied in operation, and avoid many operative com- 
plications. This proceeding has been described and illus- 
trated by the author in La Gazette des Hopitaux in 
1872 and in 18X7, and also in the seventh volume of his 
"Lemons de C'linique ( 'hirurgicale." The method consists 



especially in operating from the centre to the periphery, 
so that the surgeon reaches the great vessels and the im- 
portant organs, which are generally on the external sur- 
face of the tumor, only when the operation is drawing to 
an end. This is especially a consideration of much inter- 
est when dealing with tumors which occupy a dangerous 
region. Many tumors which are considered almost beyond 
the range of operation in such regions, especially when 
very large, have come easily within the reach of the knife 
by this method. Thus, the ablation of voluminous tumors 
of the neck, of the thyroid gland, face, abdomen and pelvis, 
is carried out with great rapidity and facility, and with 
very little loss of blood with the aid of forcipressure. 

For the piecemeal enucleation of soft tumors and of tu- 
mors of the bones, M. Pean employs special cutting-for- 
ceps, — "pinces emporte- piece," — which easily remove 
masses of the substances dealt with. For operations on 
the bones, he has for nearly twenty years employed an in- 
strument constructed by Mathieu, the well-known surgical 
instrument maker, called the polytritome, which he consid- 
ers of the first importance. By the aid of this instrument 
trephining and sections of the bone can be rapidly carried 
on, and it also allows the operator subsequently to remove 
portions in pieces as he desires. For the skull, for exam- 
ple, instead of trephining with one crown of the trephine, 
he is enabled, with the polytritome, to employ five or six 
circles of the trypan, and with his pince emporte-piece he 
removes all the intervening portion as quickly as if he 
were operating on the soft parts. For the maxillary bone, 
without looking for the special landmarks, which are care- 
fully sought out in order to introduce the chain-saw, 
M. Pean simply makes a preliminary incision, removes the 
maxillary bone by morcellement, beginning at the centre, 
and in ten minutes he arrives at the periphery and com- 
pletes the operation. So, also, for the ribs, — in lieu of 
cutting the rib, he takes the emporte-piece, removes the rib 
in pieces after having detached the periosteum, without 
troubling himself about the neighboring organs. In the 
same way he has removed without difficulty, with the poly- 
tritome and the emporte-piece, enormous enchrondromata, 
which projected into the pleura and partly filled it, or into 
the ilium. Whenever he has to deal with a bony tumor, he 
attacks it similarly from the centre, so that he never has 
any fear lest he should injure the viscera in the neighbor- 
hood of the operation. 

The substitution of the haemostatic forceps for the com- 
mon ligature is now pretty generally adopted by the French 
surgeons. For instance, in vaginal hysterectomy they have 
substituted for ligature of the broad ligaments the applica- 
tion of long curved forceps for continuous pressure on the 
folds of the membrane, these forceps being intended to 
insure haemostasis, and left in situ for twenty-four or forty- 
eight hours. This practice, due to Dr. Pean and Dr. Rich- 
elot, is considered to have considerably simplified the man- 
ual proceeding in an operation, on the value of which 
opinions are, however, divided. Dr. Pean applies this 
method of forcipressure to the treatment of aneurisms of 
the limbs. In this method compression replaces the liga- 
ture. According to the author, the seats of aneurisms 
cause considerable differences in the latter. An aneurism 
of the hand has no gravity whatever; a femoral or a pop- 
litoeal aneurism is a serious lesion. If it concerns a diffuse 
aneurism of the hand or of the foot, the forceps should be 
placed above and below the aneurism. If the aneurism is 
circumscribed, the sac should be removed after having 
compressed the artery. Antiseptic dressing, compression 
and immobility complete the cure. If one has to do with 
a diffuse aneurism of the poplitoeus, the poplitoeal artery 
should be compressed above and below the sac, as also all 
the collateral branches. The forceps should be left in situ 
for thirty-six or forty-eight hours. If secondary haemor- 
rhage should be produced, the ends of the arteries should 
be taken up and compressed. The author considers this 
method of compression superior to the ligature. It is 
more prompt, arteries are less liable to be injured than 
with the ligature, which denudes the arterial surface to a cer- 
tain extent, thus producing the tearing of the vasa-vasorum. 



Vol. CXXIII, No. 1.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



23 



Dr. Pean's achievements in surgery are most remark- 
able, and many of them prove the great advantage of sur- 
gical interference in what may he termed strictly medical 
eases. He has within the last few years successfully re- 
moved about twenty tumors affecting the brain or its cov- 
erings, in patients, however, in whom there were physical 
signs which pointed to the seat of such tumor. He is an 
untiring worker. Endowed with a vigorous body and an 
active brain, he finds no pleasure in rest. His voluminous 
works testify to his zeal and fertility as a writer, and the 
clinical material they embody shows an amount of personal 
experience seldom acquired by a man of his age. He has 
invented a variety of operative proceedings and of instru- 
ments, of which a description is to be found in the volumes 
of clinical lectures which he publishes every two years. 

As one of the most remarkable achievements in surgery 
due to Dr. Pe!an is the total ablation of the bones of the 
face, a note on which he communicated to the Academy of 
Medicine on January 14, 1890. The case was that of a 



woman aged thirty-two years, who was the subject of mul- 
tiple tumors of the bones of the face, in which the sphenoid, 
the three maxillary and the malar bones were affected by 
osteo-libromata consecutive to dental heterotopics. The 
operation was most successful; and in conjunction with 
Mr. J. P. Michaels, a dentist, who undertook the protheti- 
cal part, it reflects the greatest credit on both surgeon and 
dentist, not only in an susthetical point of view, but the 
functions of the mouth, throat and nose have been restored 
to almost their normal condition. 

Notwithstanding the preeminent qualities possessed by 
Dr. l'ean, he was, for reasons best known to the members 
of the Academy of .Medicine, not received among them till 
about two years ago, although he had more than once 
presented himself as a candidate. Some attribute this 
circumstance to professional jealousy, others say that, 
although he is a first-rate surgeon, he was not considered 
sufficiently a savant to have the portals of the Academy 
opened to him. 



REPORTED MORTALITY FOR THE WEEK ENDING JUNE 21, 1890. 













Percentage of Deaths 


from 






Estimated 


Reported 


Deaths 












Cities. 


Population 
for 1890. 


Deaths in 
each. 


under Five 
Years. 


Infectious 


Acute Lung 


Diphtheria 


Diarrhceal 


Typhoid 










Diseases. 


Diseases. 


and Croup. 


Diseases. 


Fever. 


New York . . . 


1,622,237 


773 


367 


23.01 


11.70 


4.68 


15.73 


.39 




1,100,000 


292 


107 


14.96 


8.50 


3.40 


4.76 


9.32 




1,064,277 


480 


247 


14.04 


10.71 


2.10 


18.06 


2.31 




852,467 


370 


202 


26.46 


11.34 


it Oft 


15.93 


.21 




550,000 


212 


123 


30.08 


7.32 


2.35 


23.03 


.47 




500,343 


254 


141 


34.32 


7.02 


.78 


29.64 


1.56 




418,110 


166 


41 


9.60 




4.20 


2.40 


1 80 




325,000 


146 


66 


28.29 


12.42 


4J4 


20.70 




New Orleans .... 


260,000 


173 


84 


26 68 


5.80 




1 Q Id. 


1.16 




210,000 


















240,000 


















230,000 


121 


66 


35.86 


6.64 


4.15 




5.81 




68,513 


34 


13 


29.40 


5.88 






5.88 




60,145 


42 


21 


28.56 


4.76 




16.66 


2.38 




42,000 


13 


2 


7.69 












81,622 


26 


8 


11.55 


15.40 










73,370 


32 


12 


25.00 


12.50 


3.13 


C.26 


9.39 




67,026 


19 


8 


5.26 


10.52 


5.26 






Fall River 


64,092 


17 


5 


23.52 


17.64 




23.52 






55,200 


9 


1 


9.09 


9.09 






9.09 




41,520 


8 


1 


12.50 


12.50 


12.50 








41,058 


19 


6 


15.78 


21.04 


5.26 






New Bedford .... 


38,218 


11 


5 


9.09 


9.09 




9.09 






37,867 
















35,516 


















30,811 


















29,242 


8 


5 


25.00 


25.00 


12.50 








28,781 


5 


2 . 














27,124 


9 


6 


22.22 


11.11 




11.11 






25,544 


4 


1 


25.00 












24,904 


3 







33.33 










22,011 


4 







25.00 










20,615 


5 





20.00 




20.00 








17,998 


4 


1 














17,304 


5 


3 


20.00 










Attleborough .... 


15,994 
















Pittsfield 


15,762 


2 

















14,114 


5 


1 




40.00 








Newbury port .... 


13,915 


















13,089 

















Deaths reported 3,275 ; under five years of age 1,546 : principal 
infectious diseases (small-pox, measles, diphtheria and croup, 
diarrhceal diseases, whooping-cough, erysipelas and fevers) 827, 
consumption 331, acute lung diseases 260, diarrhceal diseases 
549, diphtheria and croup 104, typhoid fever 67, scarlet fever 
31, measles 25, cerebro-spinal meningitis 23, malarial fever 22, 
whooping-cough 21, erysipelas 8. 

From scarlet fever New York 11, Brooklyn 5, Chicago 4, St. 
Louis and Cincinuati, 3 each, Philadelphia and Worcester 2 each, 
Baltimore 1. From measles, New York 10, Philadelphia and 
Brooklyn 3 each, Chicago, Baltimore and New Orleans 2 each. 
Washington, Charleston and Lawrence 1 each. From cerebro- 
spinal meningitis, Washington 5, Chicago and St. Louis 4 each, 
Brooklyn and Cincinnati 2 each, Philadelphia, Boston, Worcester, 
Taunton and Fitchburg 1 each. From malarial fever, New 
Orleans 9, Brooklyn 5, New York and Baltimore 3 each, 
Philadelphia and Charleston 1 each. From whooping-cough, 



New York 8, Philadelphia, Brooklyn, St. Louis and Charleston 
2 each, Chicago, Boston, Portland, Lowell, and Salem 1 each. 

From erysipelas, New York 4, Chicago 2, Brooklyn and Law- 
rence 1 each. From puerperal fever Philadelphia, Brooklyn, 
Washington and Lowell 1 each. 

In the twenty-eight greater towns of England and Wales with 
an estimated population of 9,715,559, for the week ending June 
14th, the death-rate was 17.2: deaths reported 3,199: Infants 
under 1 year 684, acute diseases of the respiratory organs 
(London) 240, measles 148, whooping-cough 93, scarlet fever 51, 
diarrhoea 39, fever 36, diphtheria 33, small-pox (Plymouth) 1. 

The death-rates ranged from 9.6 in Nottingham to 26.2 in 
Manchester: Birmingham 17.2, Bradford 17.1, Hull 15.1, Leeds 
17.9, Leicester 13 2, Liverpool 20.7, London 16.2, Norwich 14.2, 
Portsmouth 19.3, Sheffield 21.0, Sunderland 19.5, Wolverhamp- 
ton 22.5. 

In Edinburgh 16.1, Glasgow 25.5, Dublin 25.3. 



24 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 3, 1890. 



The meteorological record for the week ending June 21, in Boston, was as follows, according to observations furnished by 
Sergeant J. W. Smith, of the United States Signal Corps :- 



Barom- 
eter. 



30.10 
30.26 
30.11 
29.88 
129.88 
30.16 
30.06 



Thermometer. 



58.0 
64.0 
68.0 
76.0 
70.0 
61.0 
64.0 



61.0 
75.0 
79.0 
87.0 
79.0 
67.0 
71.0 



56.0 
52.0 
56.0 
64.0 
62.0 
56.0 
57.0 



Relative 
Humidity. 



83 
91 
84 
72 
47 
58 



Direction of 
Wind. 



N.E. 
S.W. 

W. 

W. 
N.W. 
N.E. 
S.W. 



N.E. 
S.W. 
S.W. 

w. 

N.E. 

S. 
S.W. 



Velocity of 
Wind. 



12 
2 
13 
12 
13 
8 
12 



12 
12 
is 
11 

5 
11 

9 



State of 
Weather.* 



*0., cloudy ; C, clear ; F., fair ; G., fog ; H., hazy ; S., smoky ; R., rain ; T., threatening ; N., snow, t Indicates trace of rainfall. 



OFFICIAL LIST OF CHANGES IN THE STATIONS AND 
DUTIES OF OFFICERS SERVING IN THE MEDICAL DE- 
PARTMENT, U. S. ARMY, FROM JUNE 12, 1890, TO JUNE 
27, 1890. 

By direction of the Secretary of War, leave of absence 
for three months and fifteen days, to take effect as soon as his 
services can be spared, is granted Captain William C. Bordbn, 
assistant surgeon. Par. 11, S. O. 148, A. G. O., June 23, 1890. 

Captain Howard Culbertson (Retired) died June 18, 1890, 
at Zanesville, Ohio. 

APPOINTMENTS. 

To be Assistant Surgeons with the rank of First Lieutenant: 
Frank R. Keeper, of Pennsylvania, June 2(i, 1890, vice 

Woodruff, promoted. 
Thomas U. Raymond, of Indiana, June 6, 1890, vice Newton, 

resigned. 

Henry D. Snyder, of Pennsylvania, June 0, 1890, vice Wil 
son, resigned. 

Allen M. Smith, of New York, June 6, 1890, vice Matthews, 
promoted. 

Ashton B. Heyl, of Pennsylvania, June 6, 1890, vice Hall, 
promoted. 

Joseph T. Clarke, of New York, June 6, 1890, vice Porter, 
resigned. 

By direction of the Secretary of War, Major Charles R. 
Greenleaf, surgeon, will attend the encampment of the 
Pennsylvania National Guards, at Mount Gretna, Pennsylvania, 
from the 18th to the 26th of July, 1890, for the purpose of accom- 
panying the surgeon-general of Pennsylvania in his inspection 
of the camp. Par. 11, S. O. 144, A. G. O., June 20, 1890. 

Leave of absence for one month, on surgeon's certificate of 
disability, is hereby granted Captain Marcus E. Taylor, 
assistant surgeon, with permission to go beyond the limits of 
this division, and to apply for an extension of five months. 
Par. 1, S. O. 45, Division of the Pacific, San Francisco, Cal., 
June 13, 1890. 

By direction of the Secretary of War, Major Samuel M. 
IIokton, surgeon U. S. Army, will visit the encampment of the 
Maine Volunteer Militia, at Augusta, Me., during the period of 
its encampment, June 30, to July 4, 1890, inclusive, for the pur- 
pose of instructing the medical department thereof in its duties 
in camp, and on completion of this duty will return to his 
proper station. S. O. 143, paragraph 5, Adjutant-General's 
office, Washington, D. C, June 19, 1890. 



OFFICIAL LIST OF CHANGES OF STATIONS AND DUTIES 
OF MEDICAL OFFICERS OF THE UNITED STATES MA- 
RINE-HOSPITAL SERVICE, FOR THE THREE WEEKS 
KNDING JUNE 21, 1890. 

Gassaway, J. M., surgeon. When relieved at Cairo, 111., to 
proceed to New Orleans, La., and assume command of the ser- 
vice at that, station. June 4, 1890. 

Stoner, G. W., surgeon. Granted leave of absence for three 
days. June 18, 1890. 

Wasdin, Eugene, past assistant surgeon. Granted leave of 
absence for fourteen days. June 5 and 10, 1890. 

White, J. 11., past assistant surgeon. To proceed to Savannah, 
Ga., on special duty. June 9, 1890. 

Heath. F. C, assistant surgeon. Granted leave of absence 
for tilty-eight days. June 1U, 1890. 

Maoruder, G. M., assistant surgeon. Granted leave of 



absence for twenty days. June 2, 1890. Ordered to examina- 
tion for promotion June 5, 1890. 

Woodward, R. M., assistant surgeon. Relieved from duty 
at Chicago, 111., to assume command of service at Cairo. 111. 
June 4, 1890. 

Condict, A. W., assistant surgeon. Upon expiration of leave 
of absence to report to medical officer in command at Chicago, 
111., for duty. June 4, 1890. 

resignation. 

Heath, F. C., assistant surgeon. Resignation accepted by 
the President, to take effect August 31, 1890. June 10, 1890. 



OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS 
OF THE U. S. NAVY FOR THE WEEK ENDING JUNE 
28, 1890. 

Page, John E., Berry ville, Va. ; 

Kennedy, Robert M., Pottsville, Pa. ; 

Whitefield, James M., Richmond, Va. ; 

Stone, Lewis H., Litchfield, Conn.; 
have been commissioned assistant surgeons in the Navy. 

Atlee, Louis W., assistant surgeon, detached from the 
U. S. S. " Marion," and granted three months' leave. 



OBITUARY. HOWARD CULBERTSON, M.D. 

Dr. Howard Culbertson, of Zanesville, O., died Juue 18th, 
after a week's illness, the result of acute dysentery contracted 
in the army. He was born in Zanesville in 1828. In 1848 he 
graduated from Jefferson Medical College, Philadelphia. At 
the beginning of the Civil War he offered his services to the 
Union, and in 1862 was appointed surgeon of Ohio Volunteers, 
and was brevetted lieutenant-colonel in 1865. On February 28, 
1806, he was appointed a surgeon of the United States Army, 
and remained in the service until January 8, 1809, when he was 
retired on account of disability contracted in the line of duty. 
He was the author of several works on medicine and surgery, 
the one "Excision of the Larger Joints of the Extremities," 
being recognized as a standard authority both in America and 
Europe. In 1876-77, he was professor of ophthalmy in the 
Columbus Medical College, and at the time of his death he was 
assistant editor of the American Journal of Ophthalmy, pub- 
lished at St. Louis. 



BOOKS AND PAMPHLETS RECEIVED. 

Clostridial Nephritis : a Research conducted at Cooper Medi- 
cal College. By F. V. Hopkins, M.D. Reprint. 1890. 

Fifteenth Annual Announcement and Catalogue of Meharry 
Medical Department, Central Tennessee College, Nashville, 
Tenn. 1889-90. 

A Treatise on Neuralgia. By E. P. Hurd, M.D., Member of 
the Massachusetts Medical Society, etc. Detroit, Mich. : George 
S. Davis. 1890. 

Contribution a l'Etude de la Syringomyc'lie. Par le Docteur 
I. Bruhl, Ancieu Interne des Hopitaux de Paris. Paris Aux 
Bureaux du Progrcs Medical. 1890. 

University Medical College of Kansas City. Formerly Medi- 
cal Department of the University of Kansas City, Missouri. 
Tenth Annual Announcement and Catalogue of Session 1889-90. 



Vol. CXXIII, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



25 



lecture. 



INFLUENZA IN MASSACHUSETTS. 1 

BY (iliOKGK I!. H1IATTUCK, M.I>., OK BOSTON. 

Mk. President and Fellows op the Massa- 
chusetts MEDICAL Society : As you well know 
the time-honored Annual Discourse takes place as 
usuul to-morrow, on the last day of this meeting, just 
before the annual dinner, and is uuquestionably looked 
forward to this year with all of the usual interest. 
That an additional claim should be made upon your 
time and attention this evening is an innovation, and 
as such requires some words of explanation. 

At the annual meeting of the Society in the year 
1858 the treasurer reported that, "the Society has 
come into the enjoyment of the Shattuck legacy, 
amounting to $9,166.87, the income from which will 
contribute largely towards meeting the expenses of 
publication to which it is especially designated." Since 
that time this fund has remained with the Massachu- 
setts Hospital Life Insurance Company, invested in one 
of that compauy's annuity policies, and has yielded in- 
terest varying from 8.25% in 1866, and during the 
period of inflation just after the war, which was the 
highest rate, to 4% which has been the rate annually 
during the last ten years. It appears from the treas- 
urer's accounts, as your present treasurer kindly informs 
me, that until 1872 the income was expended for 
printing, binding and distributing the "Annual Com- 
munications." In 1872, however, the entire income 
is entered on the credit side of the funds as " loaned to 
the Massachusetts Medical Society." This arrange- 
ment was continued from year to year until 1877, 
when, the unusual necessities of the Society appar- 
ently having ceased, the former use was renewed and 
the income again paid for printing and distributing the 
medical communications. 

In 1878 a prize was offered by the Society for a 
prize essay, which was gained by Dr. Thomas Dwight 
by a very admirable piece of work on " Identification 
of the Human Skeleton " ; and the income was devoted 
to the payment of the award and to the publication and 
distribution of this essay. During the subsequent years 
it has been expended as previously upon the annual 
medical communications, except in the years 1886, 
1887 and 1888, when it was allowed to accumulate, 
and a prize of $1,000 was offered for competition at 
large for an essay worthy of a prize, on " The Climate, 
and its Modifications as influencing Health and Disease, 
or on any of the diseases of the inhabitants of New 
England, or on any kindred subject." This prize 
failed to excite the interest and stimulate the competi- 
tion which was anticipated from the offer of so consider- 
able a sum of money, with such a wide range of subjects, 
and no award was made. A result which emphasized 
observations elsewhere made as to the diminished zeal 
for the capture of prizes, whether baited with a round 
sum of money or with a long established reputation 
stamped upon a medal. The time when the possession 
of a Boylstou Prize was the almost necessary passport 
to subsequent professional advancement and reputation 
in this immediate community is in a somewhat distant 
past. Perhaps the appearance on the scene of the 
professional prize-taker has had the same limiting effect 
as the professional influence has had in other contests. 

1 Delivered before the Massachusetts Medical Society June 10, 
1890. 



Be the reasons what they may, prizes seem no longer 
to attract as formerly. 

In the years 1806 and 1807 no less than three of the 
Boylstou Prize Medals were secured by Dr. Shattuck's 
pen, but in 1888 your committee came somewhat 
reluctantly to the conclusion that what our forefathers 
termed in 1807 the " beneficient and laudable view of 
improving the art of medicine, and the excitation of 
practitioners to bring those talents to light which might 
otherwise be useless to the community," were not best 
subserved by the offer of prizes, and accordingly your 
council in 1888 voted : 

"That the Committee on Publications be instructed 
to provide for a lecture, to be called the Shattuck Lec- 
ture, on some subject in accordance with what is speci- 
fied in the will of the late Dr. Shattuck, the lecture 
to be delivered at the annual meeting of the Society." 

In accordance with this vote the Committee in charge 
proceeded to its execution, and, apparently, impressed 
with the feeling that it was not intended that only the 
sins of the fathers should descend upon the children, 
they appointed me to deliver the first Shattuck Lecture 
before the Society. 

I confess I should have been very glad for your sakes 
and for that of the Lectureship had the choice fallen on 
a more competent person, but neither my appreciation 
of the courtesy of your Committee nor my respect for 
the memory of the benefactor, after whom the Lecture- 
ship is named, would permit me to decline. 

You, therefore, see why it is that you are called upon 
to listen to a lecture on the evening of the first day of 
the annual meeting, as well as to the discourse on the 
second day; I hope the process will not serve simply 
to increase your respect for the more carnal provisions 
of the Cotting Fund. 

As the first to discharge the duties of this lectureship 
it may be thought proper and pardonable if I ask you 
to accompany me a little while in a further brief con- 
sideration of the circumstances which gave rise to its 
foundation, and of the scope of its functions, thus leav- 
ing a clearer field to the legitimate and more important 
duties of my successors. 

The fund bequeathed by Dr. Shattuck to the Massa- 
chusetts Medical Society was one of three equal funds 
left by his will to three different societies ; the other 
two being the Massachusetts Society for Promoting 
Agriculture and the Massachusetts Charitable Mechanic 
Association. The provisions of the bequest in behalf 
of this Society were that it " should apply the net in- 
terest and income of the same from time to time, in the 
discretion of the Society, or of its government, to the 
collection and publication, annually, by some suitable 
person or persons, of historical or other essays on the 
climate of said Commonwealth, on the diseases of its 
inhabitants, and on such other subjects as the said So- 
ciety or its government may select." 

The bequest to the Massachusetts Society for Pro- 
moting Agriculture — the oldest incorporated society 
but one in this State — provided that " the net income 
of its fund should be applied from time to time, in the 
discretion of the Society or its government, to diffuse 
a knowledge of the proper admixture of soils, so as to 
raise the greatest quantity of food with the least labor 
and expense ; to encourage the raising of trees for fuel 
and ship-timber ; and generally to disseminate a knowl- 
edge of practical agriculture." 

The bequest to the Charitable Mechanic Association 
provided that " it or its government should apply the 



26 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 10, 1890. 



net interest of the fund from time to time, at discre- 
tion, to encourage improvements in architecture, and 
especially in the mode of constructing cheap and con- 
venient dwellings for the poor, and also in defraying 
the expense of instructing mechanics' apprentices in the 
knowledge of the useful arts." 

As has been shown by the hasty review of the uses 
to which this Society has put the income of its funds, 
the medical objects which the donor had in mind and 
at heart, have been, to a considerable extent, realized. 
The Society for Promoting Agriculture, with a total 
fund of about $120,000, has done much for the farmer 
of the State of Massachusetts in improving the breeds 
of various domestic animals by the importation of for- 
eign stock, and in other ways has disseminated a 
knowledge of practical agriculture; but I cannot learn 
that it has caused studies to be made of the proper ad- 
mixture of soils, so as to raise the greatest quantity of 
food with the least labor and expense, or has encour- 
aged the raising of trees for fuel and ship-timber. 
The generation which has grown up to man's estate 
since this bequest was made has solved those questions 
for itself in a different but a very practical way — by 
moving West to the plaius, and to the forests of Mich- 
igan and Puget's Sound ; but even there at no distant 
date, if things go on as they have done, if there is no 
rotation of crops and unchecked forest fires, such in- 
formation as Dr. Shattuck thought desirable for Massa- 
chusetts in 1854 may not be superfluous. 

On the other hand, singularly enough, with the in- 
creased knowledge of the diseases of domestic animals 
and of their relation to those of man, and with the de- 
velopment of veterinary science, it has come to pass 
that this same Agricultural Society, through Drs. 
Peters and Ernst, is employing a portion of its income 
in an investigation of tuberculosis — a disease than 
which there is none more prevalent, none causing so 
many deaths in this State and throughout New Eng- 
land — and is thus doing work of a kind which, thirty- 
rive years ago, could only have been expected to emanate 
from medical sources. 

The Charitable Mechanic Association has hitherto, I 
believe, done little or nothing towards realizing the 
specific wishes expressed by the testator, and certainly 
nothing especial towards encouraging improvements in 
the mode of constructing cheap and convenient dwell- 
ings for the poor. But other agencies have, in a cer- 
tain measure, brought about this very desirable end, 
and capital, philanthropy and hygiene have all found a 
remunerative account therein. 

From the last annual report of the trustees of the 
Peabody homes for the poor in London, in which es- 
pecial attention was given to sanitary construction, it 
appears that the birth-rate in these homes is 8.72 per 
1,000 above the average, the infant mortality is but a 
little over half the average, and the total death-rate is 
1 per 1.000 below the average. Yet these buildings 
pay a moderate percentage upon the amount invested, 
although their construction can hardly be called cheap. 
Here in Boston there are now numerous tenement- 
houses, which fairly deserve the name of apartment- 
houses, occupied by poor people, where the sanitary 
conditions are good, the standard of health is high, 
there is no overcrowding, and which pay fair returns to 
the owners. There is also a Cooperative Building 
Association which aims to secure the ends sought for 
in this legacy, and thus indirectly lowers the death-rate 
of the city. 



These bequests were not large — even for the day 
in which they were made, certainly not for ours — and 
were individually smaller than others proceeding from 
the same source, but they were eminently characteris- 
tic of the man, eminently indicative of his interests 
during life and of the direction which his hopes for the 
future took. He was not a sentimentalist, but nothing 
human was foreign to him ; he was at home with all 
sorts and conditions of men, he had a constant interest 
in and sympathy for humanity. He knew the farmer, 
he knew the mechanic, he knew the homes of the poor. 
His father, a graduate of Harvard, a man of large 
frame and powerful physique, spent his strength as a 
country doctor in the last century, going on horse-back 
over the hilly regions of the northern part of Worces- 
ter County, succumbed to the exposure and labor of 
his profession at the early age of fifty-one years, and 
leaving his son an orphan at the age of eleven years. 
Hence, he knew, too, what it was to make one's own 
way ; he knew — to use his own quaint expression — 
the value of the " healthy stimulus of prospective 
want," but he also knew the value of encouragement 
and of a helping hand held out at the right moment. 

He himself graduated at Dartmouth College. As a 
medical student part of his time was spent at the Uni- 
versity of Pennsylvania, where he took his degree in 
1807. He obtained a knowledge of country practice 
by studying with Dr. Amos Bancroft in Weston, and 
of city practice in connection with Dr. Danforth in 
Boston. He had previously received a medical degree 
from Dartmouth, and subsequently a third medical 
degree from Harvard. So that, although not having 
studied abroad, his medical education was, for that 
time, a broad one. 

While in Philadelphia, as his letters written from 
there show, he undoubtedly came under the influence, 
to some extent, of Dr. Benjamin Rush, who was then 
at the height of his reputation as a teacher, and who 
was a large figure in the society of the time, and he 
was one of comparatively few from this neighborhood 
who came directly in contact with Rush. Of Rush, 
Dr. Holmes said, addressing this Society in I860: 2 

" If I wished a student to understand the tendencies 
of the American medical mind, its sanguine enterprise, 
its self-confidence, its audacious handling of Nature, 
its impatience with her old-fashioned ways of taking 
time to get a sick man well, I would make him read 
the life and writings of Benjamin Rush. Dr. Rush 
thought and said that there were twenty times more 
intellect and a hundred times more knowledge in the 
country in 1799 than before the Revolution. His own 
mind was in a perpetual state of exaltation, produced 
by the stirring scenes in which he had taken a part, 
and the quickened life of the time in which he lived. 
It was not the state to favor sound, calm observation. 
He was impatient, and Nature is profoundly imperturb- 
able. . . . Dr. Rush must have been a charming 
teacher, as he was an admirable man. He was ob- 
serving, rather than a sound observer ; eminently 
observing, curious even, about all manner of things. 
But he could not help feeling as if Nature had been a 
great deal shaken by the Declaration of Independence 
and that American art was getting to be rather too 
much for her — especially as illustrated in his own prac- 
tice. He taught thousands of American students, he 
gave a direction to the medical mind of the country more 
than any other one man, perhaps he typifies it better 

'Currents and Counter-Currents. Annual Meeting, May 30, 1860. 



Vol. CXXIII, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



27 



than any other. It has clearly tended to extravagance 
in remedies and trust in remedies, as in everything else, 
etc., etc." 

Dr. Weir Mitchell, his fellow-townsman, on the 
Other hand (A Commemorative Address delivered at the 
Centennial Anniversary of the Institution of the Col- 
lege of Physicians of Philadelphia, 1887), says of 
Rush : 

" With reverent doubt of my powers to do justice to 
the greatest physician this country has produced, I ap- 
proach the task of recalling to your memories the vivid 
and emphatic personality of Benjamin Rush. His life 
invites a less hasty biographer, and is full of such seem- 
ing contradictions as can only be explained by the 
belief that the earnest, decisive, and mutinous nature 
of a man, proud rather than conceited, got the better 
of the principles by which he honestly strove to guide 
his conduct. . . . How shall I briefly bring before you 
the career of this restless being? Relentless energy 
drove him through a life in which ardent sense of duty, 
large-minded philauthropy, love of country, devotion 
to his art and its science, immense belief in himself, 
were the motives to industry. . . . He was a statesman, 
a scholar, an army surgeon, a punctual and careful 
physician, an actively religious man, a far-seeing and 
courageous philanthropist, and a sanitarian far in ad- 
vance of his day. These are what I might call four 
careers, in all of which he excelled, unaided by secre- 
taries or modern means of condensing aud regulating 
labor; one such suffices most men." 

Ur. William Pepper, another Philadelphian, says of 
Rush : 3 

•' Rush was evidently a perfectionist. His enthusi- 
asm over the possibilities of human nature continually 
breaks out into expressions of sincere exuberance. I 
fear he drew his inspirations more from the experience 
of his own nature, refined and elevated, which required 
no excitement but the claims of duty, aud no pleasure 
but the pursuit of knowledge and truth, than from the 
observation and study of men as they actually exist. 

" The truth is that Rush was at all times and in all 
places and before all else a great physician. He had 
entered public life from a sense of patriotic duty ; he 
had labored for the improvement of society because he 
was irresistibly impelled by his large humanity ; but 
he threw himself iuto the service of medicine with 
passionate intensity. Ramsay, a favorite pupil and 
intimate friend, tells us that Rush wrote to him: 
' Medicine is my wife, science is my mistress, books 
are my companions, my study is my grave.' " 

Dr. Shattuck shared to some extent the tendency 
of his day to polypharmacy ; he did not eschew reme- 
dies of large bulk, he did not always think it necessary 
to stoop to tickle the palates of his patients, he had 
confidence in medicines, as he had in other methods of 
interfering with disease, and used them with courage 
when he thought interference necessary. But I do 
not think, in his case and in that of many others in 
New England, of whom he was a good type, that this 
was so much because he thought " there were twenty 
times more intellect and a hundred times more knowl- 
edge in the country in 1799 than before the Revolu- 
tion " ; so much because he " felt that Nature had 
been a good deal shaken by the Declaration of Inde- 
pendence, and that American art was getting to be too 
much for her " ; in other words so much due to the 

* Address delivered before the American Medical Association, June, 
1889. 



influence of the teaching of Rush — as it was due to 
a mental and moral inheritance typical of his time. 
His lather, as has been said, had carried on a guerilla 
warfare with disease over the hills and valleys of 
Worcester County for twenty-five years until he fell 
before it himself ; his grandfather, a farmer, at the 
age of sixty-five shouldered his gun and followed the 
British on the 19th of April, 1775, from Lexington 
to Cambridge, having previously marched from Little- 
ton ; and his great-grandfather, also a Harvard gradu- 
ate, was an Orthodox clergyman whose life was a 
contest with false doctrine, with the flesh and the devil. 
This was not a paternity for a contemplative offspring, 
for an expectant generation, for a hand-folding philos- 
ophy. It was in the blood to be up and doing, to 
wrestle with some antagonist and to strive to prevail 
over him ; whether the antagonist took the form of a 
vigorous climate, of depravity of the spirit, of unjust 
taxation or of weakness and error on the part of the 
flesh. It was just possible for the strong men of that 
generation to sit down and see Nature lead, but not to 
restrain themselves from pursuing and taking hold of 
her when she led us it seemed to them astray. It 
was their duty to smite the Philistine, not to leave 
him the chances of the slow corrective influence of 
time. 

The self-determining power of the will, which had 
accomplished much in the preceding two hundred 
years, had not abdicated in the early part of this cen- 
tury, nor yet had it adopted the gentle disguises 
of Christian Science, of the mind-cure or of hypnotism. 
Bad medicine was good for disease, as self-torture was 
good for the erring. We take both our religion and 
our medicine more comfortably and less seriously. 
But then he who took a distasteful remedy had placed 
his comfort as a precious sacrifice upon the altar of 
health. The nose of the patient as of every one else 
must be kept to the grindstone. 

It was felt that the doctor's duty was to stand be- 
tween the patient and the disease, but not always 
with the apothecary at his side, as appears from old 
letters of Dr. Shattuck's which have been preserved. 
A young clergyman, whose first vigor was spent, is 
sent on a horseback journey with a companion. An- 
other clergyman, whose delicate wife was suffering in 
1825 from some early form of tuberculosis, is ad- 
vised : " If your wife can conform to rule in diet and 
exercise and exposure she may be restored. If the tram- 
mels are too galling to her free agency she slackens the 
progress of cure and reuders her situatiou still pre- 
carious. Let her case terminate as it may I feel that 
I have honestly intended her service. I am sorry 
that instinct rather than reason governs one so elevated 
among the national tribes." And a year later, after the 
death of this patient who lived at a distance : " I 
became quite convinced when I learned her impatience 
under the use of the only earthly means that could 
serve her (namely, warmth, rest, diet, good nursing, 
with the healing hand of time) that she could not at- 
tain health more." 

To a college professor, who asks as to his probable 
future health aud ability to continue in the discharge 
of his duties, notwithstanding an impaired constitu- 
tion, Dr. Shattuck wrote in 1826 : " Your diet, wear- 
ing apparel, exercise iu the open air, warmth and 
ventilation of your apartment, bathing (medicated, 
warm and shower), attention to an easy state of 
bowels, and attentiou to a wholesome variety in your 



28 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 10, 1890. 



intellectual labor and to a healthful alternation be- 
tween labor and rest, are, in my opinion, adequate 
remedies to secure you the possession of a working 
power equal to all the duties of your professorship. 
I would underwrite at a less rate at this time on your 
continued life and power to labor ten years to come, 
then I should have felt justified in doing it at when 
you were here a year ago." 

. In another letter of advice I find the following : 
" You must turn Quaker, and remain silent ; give 
your lungs rest and they will recover. After all, 
careful nursing is the most essential to you, pediluvium 
friction, diet, etc." 

Yet such expectancy, such appreciation of the cir- 
cumfusa and ingesta, such recognition of self-limitation 
proceeded from the same pen as : " Enquire of Mussey 
his opinion of the expediency of maintaining over 
your entire chest a pustular eruption for at least two 
or three months " ; or as a prescription for a thousand 
pills, three pills every day for a year, — a prescription 
the remembrance of which was treasured up unto the 
detriment of the third generation when applying for a 
hospital appointment. A compound prepared with un- 
authorized elegance for a rich and influential client at 
his request, found its way out of window instead of 
down the patient's throat, and the genuine stuff was pro- 
cured and submitted to. It is evident that the patient 
was held in view for treatment quite as much as the 
disease. Yet, when he wished to endow a professor- 
ship at the Harvard Medical School, it was a chair of 
Morbid Anatomy, not of Materia Medica and Thera- 
peutics, which was selected. 

It is true that civil commotion stirs up thought and 
quickens mental activity ; but, in spite of this, I am 
constrained to believe that the remote influence of 
Calvin had quite as much to do with the best of medi- 
cal practice during the first half of this century in 
New England, as had the immediate teaching and ex- 
ample of Rush. 

At the time the bequest which gives rise to this 
lectureship was made, the study and description of 
disease as exhibiting itself in this Commonwealth and 
in New England was in some ways easier and in some 
ways more difficult than at the present time. There 
was a much more homogeneous population, habituated 
to its surroundings and to the climate. The pursuits 
were less varied, the effects of competition and nerv- 
ous strain less great. There was less crowding and 
less movement of individuals to and fro. There was 
less division of medical practice ; there were more 
doctors, I think I may say — at least at the centres of 
population — who knew all about more people than 
now, and not merely about one member of a family 
or perhaps only about one organ of one member of a 
family. The trusted physician in the city was then, 
as is happily still the case in some parts of the coun- 
try, the adviser, not merely the prescriber, for the 
family ; he was in many ways the guide, the counsellor, 
the friend. His memory and bis note books furnished 
something nearer the theoretical bureau of domestic 
anthropometry than anything we have at present. 

On the other hand there were lacking the abundant 
facilities for rapid exchange of medical thought and 
observation all over the world which exists now ; 
and there were lacking altogether or only existing in 
a small way, the three great sources for the study of 
the development, the course and the variations of dis- 
ease in a given population, namely, boards of health, 



hospitals and a trustworthy registration of vital 
statistics. 

The Massachusetts Hospital was the only hospital 
for general diseases in New England ; our State 
Board of Health was not started until 1869, and the 
registration of vital statistics, which has been enlarged 
and improved in recent years, was first undertaken by 
the State in 1842 and was much less perfect than 
now. 

Under the circumstances, therefore, which existed 
in 1854 and the immediately preceding years, there 
was a raison d'etre and a promise for utility in a be- 
quest like this of Dr. Shattack's, such as perhaps 
would not suggest themselves, at least not with 
as much force, to-day. Certainly to one who was 
fond of and somewhat sanguine about the compilation 
of facts and figures ; who for many years was Presi- 
dent of the American Statistical Association ; who 
was a friend and supporter of Lemuel Shattuck — 
one of three commissioners, as Dr. Walcott reminded 
you last year, appointed in 1849 under the authority 
of this Commonwealth to make a sanitary survey of 
the State — to such a one the objects for which he 
designated this bequest, must in the early fifties have 
appealed with peculiar force. 

Every well regulated hospital may be regarded as 
a post-graduate school whose courses, if rightly fol- 
lowed, should make some additions to the reliable 
records of clinical observations and to the sum total 
of the knowledge of disease, in its neighborhood at 
least. In comparison with the single hospital thirty- 
five years ago, one finds — in addition to the large 
City Hospital of Boston, the Carney Hospital at 
South Boston, and to all the small incorporated special 
hospitals doing an admirable work in this city — that 
Lowell has two hospitals, one organized first as a 
Dispensary (?) in 1840, the other incorporated in 
1867; Lynn one hospital, opened for patients in 
1883; New Bedford two, one opened in 1873, the 
other in 1885; Cambridge one, incorporated in 1871, 
and opened for general patients in a new building 
in 1886 ; Newton one, opened in 1886 ; Newburyport 
one, opened in 1884 ; Haverhill one, opened in 1882 ; 
Salem one, opened in 1874; Quincy one, opened in 
1890; Taunton one, opened in 1889; Fall River one, 
opened in 1888 ; Worcester, a City Hospital, opened 
in 1871, and a Memorial Hospital opened in 1888; 
Clinton one, opened in 1889; Springfield, a City Hos- 
pital since 1879 ; Pittsfield, a hospital since 1884 ; 
North Adams one opened about the same time. In 
addition to these already opened and at work, plans 
are under discussion for hospitals in Maiden, Marlboro' 
and Plymouth. 

With the growth and enlargement of some of these 
hospitals, which the future is sure to bring, why may 
not fresh contributions be expected from their physi- 
cians as to the effect of locality, of certain occupations, 
of certain race admixtures upon health and diseases. 
The introduction of the Celtic element, which went on 
so vigorously during the middle third of this century, 
has had, as we all realize, an enormous influence upon 
the vital statistics of Massachusetts ; the effect of the 
French Cauadiau and the Italian immigrations will 
probably be less, but just what the future alone can 
show. The race admixture at the Boston City Hospi- 
tal is already so marked that a smattering of several 
foreign languages is by no means an unnecessary 
qualification on f-be part of those in attendance, and 



Vol. CXX1II, No. 2.J BOSTON MEDICAL AND SURGICAL JOURNAL 



29 



the behavior of the Latin race under disease offers a 
marked contrast to that of the Anglo-Saxon. 

Yon are all aware how much our State Hoard of 
Health has done for and through the profession in its 
annual publications in regard to the subjects provided 
for in this bequest; with increased liberality on the 
part of the State its work is constantly increasing; as 
a new progressive step you will be glad to know there 
is in contemplation the appointment of a salaried in- 
spector, whose duty it shall be to investigate and 
report on the causes and conditions of local epidemic 
outbreaks, in the manner in which this has been done 
by such men as Ballard, Buchanan, Thome and Rad- 
cliffe, in the service of tlie English Local Government 
Board. Here is a field of honorable medical ambition 
for the right men. 

{To be continued.) 



Original %xt\t\z$. 



J DISORDERS OF SLEEP: INSOMNIA. 1 

BY (JHAS F. FOLSOM, M.D., CO-REFEREE, 

Visiting Physician to the Boston City Hospital. 

Whkn shall we use hypnotics? In acute disease, 
particularly fevers, sleep is often a necessity, reducing 
the activity of the heart, removing more waste, and 
quieting the general excitability of the nervous system. 
In chronic disease there is frequently the same tempor- 
ary need. In incurable disorders with pain and dis- 
comfort, in the restlessness of senility, hypnotics and 
narcotics — and used freely in the last years of life — 
are almost the chief justification of our service. Often 
in mental disease they are, for a time, all but indispen- 
sable. In some neurotic people their occasional use 
can hardly be avoided. In acute nervous and mental 
disturbance from profound shock, full and continued 
doses of narcotics may dispel most threatening symp- 
toms. The individual must, of course, be taken into 
consideration. Many can be depended upon to use 
hypnotics only as directed by their physician ; others 
can no more be trusted with them than certain persons 
with alcohol. Something of slight intrinsic hypnotic 
value may be intensified by its mental effect, and I am 
sometimes deliberately asked for a prescription upon 
which to build a mind cure. It is often imperative to 
prescribe a hypnotic, where it is best that a decided 
by puotic effect should not be got. For this purpose a 
somewhat unpleasant drug is better than an altogether 
agreeable one, and the prescription which I use consists 
of a few minims of paraldehyde in a drachm of chloro- 
form water. This can be repeated in the night several 
times and be continued without harm. 

In some conditions, even with acute maniacal symp- 
toms, it is better to let the patient lie awake almost 
absolutely for two or three nights than give the 
amount of narcotics necessary to produce sleep. 

The multiplication of sleep-producing drugs has its 
advantages in trained, skilful hands to meet idiosyn- 
crasies of temperament and varying conditions of dis- 
ease. But the immense production and widespread 
use of them in the last few years must have done in- 
calculable harm. 

Very many people — highly educated as well as 
ignorant — firmly believe that if there is not a specific 

1 A paper read at the meeting of the Association of American Phy- 
sicians, Washington, May, 1890. Concluded from page 6 of the Jour- 
nal. 



for their malady the reason is that it has not been 
brought to light; and they not only demand repeated 
trials of useless remedies but assiduously follow entic- 
ing promises in regard to those that are even in jurious. 
When our advice does not meet their fancies in that 
regard they continue their search for what they crave. 

The greater one's experience, the more is he satis- 
lied how little he can do as compared with what the 
community insists upon expecting, although more and 
more convinced of the great value of that which can 
be done, of the harm of overdoing, of the need of 
minute study in each case, and of the vagueness of 
general rules of treatment. The chief indications in 
insomnia are: To give hypnotic drugs rarely and 
only in cases when other measures have failed ; to use, 
as far as it is possible, the small dose, repeating as 
needed, so as to avoid the over-action or the cumula- 
tive effect of large doses ; to be satisfied with the 
least amount of sleep that is safe if produced by 
medicine ; to avoid drugs as a rule, except for euthana- 
sia, when the mental condition is not such that all the 
after-effects can be noted ; to bear in mind the fact 
that hypnotics given to produce sleep may increase 
wakefulness; to be on guard for unpleasant or toxic 
results when any drug is given in sufficient dose to 
produce prolonged and profound sleep; to give the 
large dose when it is indicated ; to not expect the same 
action or tolerance of new medicines in sensitive pri- 
vate patients as in hospital practice. 

Of hypnotics, there are probably none that can be con- 
tinuously used for a long time in sufficient doses to con- 
trol troublesome insomnia without occasional danger- 
ous symptoms or unpleasant after-effects, although I 
have no doubt that many of the accidents reported as 
due to them are rather coincident with them than con- 
sequent upon them. Most cases, however, are not in- 
tractable to treatment, and many respond readily to 
domestic remedies, like skullcap, thoroughwort, sage- 
tea, glycerine, or hot punch, without the physician be- 
ing called, or perhaps their restlessness has been con- 
trolled by hyoscvamus, valeriau, cannabis Iudica, 
camphor. 

The advantages of spirits, wine, beer, ale, porter 
(including some of the so-called malt extracts), koumyss, 
matzoou, are well known in old age, conditions of ex- 
haustion, fevers, and generally where a cardiac de- 
pressant must be avoided ; especially if supplemented 
by vaso-motor stimulants, like ergot, digitalis, strychnia, 
coca, cocaine. A glass of champagne often acts like 
magic in the sleeplessness of a dilated heart. A few 
bottles of beer at bedtime may control persistent and 
obstinate sleeplessness which has yielded to nothing 
else. But the habitual necessity of alcohol to produce 
sleep in brain-workers indicates the nearness of the 
danger line. The disadvantages of alcohol are well- 
known and readily guarded against. 

The preparations of opium are indispensable in many 
cases — with pain, in old age, in many forms of heart 
disease. I have not found the common caution against 
opium in pulmonary and renal disease valid, and prob- 
ably no other drug can be made to so happily meet 
the indications of so many conditions, except for the 
grave danger of the morphine habit. Krafft-Ebing 
names it justly a tonic to the asthenic brain. In eu- 
thanasia, its value is shared with only ether and chloro- 
form. 

The bromides diminish the reflex excitability of the 
medulla, aud are vaso-motor excitants. Their best 



30 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 10, 1890. 



therapeutic effect, always avoiding bromidism, is got, 
as hypnotics, from divided doses given through the 
day or evening, whether in large quantity or small. 
Alone or combined with other medicines they have a 
wide usefulness. The debilitating influence from them 
may in some cases be, partly at least, met with iron or 
bark. By virtue of obstructing the heart's action, and 
producing a certain degree of muscular depression, 
they are not without objections for continued use, or, 
in some cases, occasionally. 

The great need of an unobjectionable hypnotic led 
to coustaut laboratory research, and the final discovery 
by Liebreich of chloraL-hydrate* Eickholt's schlafmittel 
kcit' k&xriv, the most powerful of pure hypnotics, having 
also some influence on pain. In sufficient dose it 
rarely fails. Alone or combined with bromides or 
morphia, it used to be, until the introduction of paralde- 
hyde, the common last resort when other narcotics had 
failed. Its depressing effect on the heart, respiration 
and vaso-motor centres, which, perhaps, includes its 
toxic or irritant action on the kidneys, and the danger 
of the chloral habit, with persistent wakefulness and 
mental enfeeblement, constitute the risks in its use. 

Croton chloral, the butyl-chloral-hydrate, or, chemi- 
cally, the chlorated aldehyde of crotonic acid, although 
not a cardiac depressant, is, in all other ways, so in- 
ferior to chloral-hydrate, besides being not readily solu- 
ble in water, that it is rarely used except with trigemi- 
nal neuralgia, in which it is less efficacious than other 
drugs. 

A less depressing hypnotic being sought for, the fat 
series came next, paraldehyde, amyl-hydrate, urethan, 
hypnone. 

Paraldehyde, 5 a polymeride of ethylic aldehyde — 
long thought second only to chloral-hydrate in power 
as a hypnotic — has much less depressing action on the 
circulation and respiration. It is especially valuable 
in conditions of mental excitement, where the duration 
of sleep may be prolonged by adding morphia. The 
physiological action is first on the cord, and then on 
the medulla. Toxic toses (ten grammes or more) pro- 
duce a sinking of blood-pressure and slowing of the 
heart beat; doses of six to eight grammes having been 
observed to give rise to nausea, headache, confusion, 
vertigo, and weak pulse. In five cases Berger found 
material reduction in the quantity of urine. In safe 
doses it is not anaesthetic or analgesic. To get a defi- 
nite hypnotic effect, the dose must be increased. Its 
acrid taste, and the disagreeable persistent odor from 
the breath are objections to its use, and even when 
largely diluted it is often objected to, on the ground of 
its being a gastro-intestinal irritant. 

The temptation to its habitual use is less than in 
alcohol, morphia, cocaine, and chloral ; the symptoms 
produced being tremor, confusion, impaired memory, 
diminished intelligence, etc. 

Dose, two to four grammes, which, if necessary, 
may be gradually increased to eight, and repeated once 
or twice in the night. 

Amyl-hydrate, 6 a tertiary amy lie alcohol, an oily, 

4 An abstract of recent articles on the new hypnotics was intended 
as an appendix to tins paper, but the amount of material (over one 
hundred foolscap p iges) was too large to justify its space, and its 
appropriateness here whether in full or condensed has seemed to 
me at least doubtful. 

> Albertoni. Berger, Uutler, Cervello, Cervello and Valenti, Clous- 
ton, ITronmuller, ffrbfaner, Henocque, Hodgson, Kenniston, Kralft- 
Ebing, Liebreich, Peretti, Quinquarcd, Kauk, Rothe, Strahan, Tchep- 
etow, v. Noorden. 

" Huschan, Dietz, Kgasse, Kskoff, Jolly, Griffith, GUrther, Lch- 
tnaun, Liebreich, Mason, Mayer, Kiegel, Saves, Scharsehmidt, von 
Mering, von Mering and Thiorfelder, Willis, Wurtz. 



colorless liquid, appears to stand in hypnotic power 
below chloral-hydrate, and above or below paralde- 
hyde, according to different observers, but with even 
less depressing action on the heart than the latter. 
It may be used in about the same dose as paraldehyde, 
being not so soluble (1 to 19 water, freely in alcohol), 
and with a much less disagreeable taste and odor. Its 
physiological action is directly on the cerebrum, and 
later on the medulla. The toxic effects from it, of 
headache, nausea, weak pulse, are less marked than 
in paraldehyde, and it is less a gastro-intestinal irritant, 
although sufficiently so to often require its administra- 
tion by rectum. 

Urethan 7 (ethylic carbamate) a mild hypnotic iu 
doses of twenty grains, is at times useful, and may 
from its ready solubility be given hypodermically. It 
is without especial depressing action on the heart, ex- 
cept in enfeebled persons. It has, like all rather 
mild remedies, proved in some cases uncertain in its 
effects, but is useful and ordinarily without disagree- 
able after-effects. 

Hyoscyamine 8 isomeric with atropine, in doses of 
^ mgm. of the sulphate, which may be given subcu- 
taneously, controls moderate mental excitement and 
sleeplessness. In larger doses similar toxic effects to 
those of atropine are observed, sometimes with mus- 
cular prostration, which may reach an alarming degree. 
Of some value in hysteria with violence, its use is very 
limited. 

Hyoscine, 9 also an alkaloid of hyoscyamus, is used as 
iodohydrate, chlorhydrate, and, preferably, hydrobro- 
mate, also hypodermically, in doses of \ to ^ or even 
1 mgm. It has a limited usefulness, especially in 
maniacal excitement, violent hysteria, delirium trem- 
ens, insomnia with agitation, in the insane and aged. 
The dose needs to be increased somewhat rapidly for 
prolonged use, and a slight excess in the quantity 
given may produce unpleasant toxic effects, which 
may even come from ^ mgm. In a certain proportion 
of cases not only is there no quieting effect from the 
drug, but the restlessness is increased. 

Chloralamide, 10 or more properly chloral-formamide, 
produced by adding anhydrous chloral to formamide, 
is decomposed again in aqueous solution (1 to 9) if 
above a temperature of 60° C, or iu crystals if above 
115° C. It is also decomposed by alkalies and alka- 
line carbonates. It is, therefore, well to give it in 
slightly acid solution, with spirit, or as an elixir, there- 
by sufficiently disguising its bitter taste. It is claimed 
that it possesses all the advantages of chloral-hydrate, 
and on account of the stimulating properties of the 
formamide, without its depressing action on the heart, 
a fact verified by the sphygmograph, the comparative 
dose being as 3 to 2. The danger from the larger 
dose, over 30 or 40 grains, is less than in chloral. Dis- 
agreeable after-effects are much less common. Some 
observers value chloralamide most highly, while others 
regard it as in no way deserving especial praise. In 
my experience, with only the small dose, it has done 
well. If it shall be proved, after full trial, to be safer 

7 Adam, Demuie, Griffith, Sausom. 

8 Clin, Egasse, Geiger, Hesse, Horn, Ladenburg, Lemoine, Reichard 
and Duquesnel, Runge, Thompson, West, Will. 

Huddee, Edlefsou and tiling, Egasse, Erb, Fischer, Githeus, Gley 
and Rondeau, Habn, Kny, Konrad, Krauss, Ladenburg, Magnan 
andLefort, Mairetand Combomalo, Maltilatro and Lemoine, Mitchell, 
Peterson and Langdon, Pitcairn, Reichard, Sligo, Thompson, Weber, 
Wentherell, West. 

10 Alt, Aulde, Cope, Egasse, Hageniann and Strauss, Hag:in and 
ITiifler, Kalacz, Kny, Langgaard, Leech, Letton, Mehriug, Norman, 
Osier. Patereon, Peiper. Rabow, Reichmaun, Robinson, Schaffer, 
Setton, Strahan, White, Wurtz. 



Vol. CXXIII, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL 



31 



than chloral, ;iud more certain than the other pure 
hypnotics, as it is claimed to be, its cheapness is in its 
favor for general use. 

Sulfonal, 11 diethylsulphondimethylmethau, is a less 
powerful hypnotic than chloral, with even less in- 
fluence on pain, but without so much, although with 
slight, depressing action on the heart. From its 
diflicult solubility, the physiological action is slowly 
produced ; a single dose may be efficient for two suc- 
cessive nights, and there is risk of the cumulative 
effect if the dose is too often repeated. It may be 
given in compressed tablets or wafers, or dissolved in 
spirit. In doses of 30 grains or less it is, in the main, 
safe, although I have seen 20 grains given each night 
for several weeks in a girl of sixteen produce stupor, 
and 20 grains, three times a day continuously, to a 
strong male adult, cause ataxia, tremor, and mental 
apathy. It has been found not always certain, and, 
in overaction, with an after-effect of somnolence, 
fatigue, depression, lack of appetite, which, from an 
over-dose, may amount to semi-coma and cardiac de- 
pression. Given in doses of 5 grains, and repeated, if 
necessary, two or three times, or of 10 or 20 grains, and 
perhaps repeated, it has proved in my hands, a hyp- 
notic of great value in producing sleep which is re- 
freshing and resembling the natural. When care has 
been taken not to give it too often or in too large 
doses, I have never seen any untoward results from 
it. In the case of a rather delicate person, 150 grains 
produced sleep with stupor for ninety-six hours, but 
no other unpleasant symptoms, except some lassitude 
and a sense of discomfort in the head. It is the most 
important and widely useful of the new hypnotics. 

Hypnone 12 (acetophenone, phenyl-methyl acetone), 
one of the aromatic series of acetones, although praised 
by Dujardin-Beaumetz, has proved in the hands of 
most investigators of little value as a hypnotic, of un- 
pleasant taste, and depressing to the respiratory and 
cardiac ceutres. 

Ural 18 (chloral-urethan) is less potent than chloral, 
and more so than urethan. It is very bitter, soluble 
in alcohol, and but little so in water. In doses of 
more than two grammes there may be transient head- 
ache and fatigue. 

Somual 14 (ethyl-chloral-urethan) contains four 
atoms of hydrogen and two of carbon more than 
chloral-urethan (ural). It appears to have no espec- 
ial advantage over chloralamide, except that it is more 
soluble. It has somewhat greater hypnotic power 
than ural. Its composition is not regarded as certain 
or its action sure. 

Acetal 15 (diaethylacetal) is an acrid hypnotic with- 
out advantages to compensate for its being a gastro- 
intestinal irritant. 

Methylal, 16 an acetal derived from formaldehyde 
and methylalcohol, a volatile liquid freely soluble in 
water, of fragrant and aromatic odor, almost tasteless, 
may be inhaled or given by mouth and hypodermi- 
cally. It has the high authority of Krafft-Ebing as 
being a safe, certain hypnotic, useful in some forms of 

11 Bornemann, Cramer, Fischer, Frankel, Funajoli, Raimondi, Grif- 
fith, Henocque, Kast, Kisch, Knoblauch, Laudan, Liebreich, Miiller, 
Otto, Rabbas, Rosen, Rosecbacn, Slago, Schmey, Schwalbe, Steiner. 

12 Bardet, Dujardin-Beaumetz, Friedel, Hirt, fCamenski, Kny, 
Kraepelin, Krauss, Laborde, Mairet and Combemale, Norman, Rot- 
tenbiller, Seifert. 

13 Albertoni, Bischoif, Campari, Poppi. 

14 Egasse, Paul, Radlauer, Robinson. 

15 Berger, Hiller, yon Mering. 

'« Haljes and Boubila, Kraftt-Ebing, Lemoine, Mairet and Combe- 
male, Matrokhin, Personali, Popoff, Richardson. 



insanity with excitement, and especially in delirium 
tremens, for which he considers it the best hypnotic 
known. He uses 0.1 gramme with 1 gramme water, 
hypodermically, repeating every two hours if neces- 
sary. The dose internally is n\, 30 to 3'j- The de- 
pressing effect on the circulation is slight, if any, and 
lie has not observed any disagreeable after-effects. 1 1 is 
contra-indicated in conditions of active cerebral hy- 
peremia. Krafft-Ebing is in doubt how to explain 
the efficacy of the extremely small dose used by him 
unless it acts indirectly rather than as a direct hyp- 
notic in producing sleep. Lemoine gives two grammes 
subcutaneously. 

Phenacetin, 17 para acet-pheuetidin, almost insoluble 
in water, soluble in alcohol, almost tasteless, may be 
given like sulfonal, in wafers and compressed tablets, as a 
powder or with brandy. As an antipyretic and antineu- 
ralgic it is not as potent as antipyrin and antifebriu, but 
it is much less a cardiac depressant. In the insomnia 
of overwork, of nervous irritation, in febrile states, or 
from headache, it is a hypnotic of great value, in doses 
of five or ten grains, repeated if necessary. In sleep- 
lessness of intense neuralgia, less than a gramme re- 
peated two or three times, as needed, is not likely 
to be effectual, the fact having been first ascertained 
that there is no intolerance of the drug. 

The possible anilin derivatives of, which phenacetin 
(para-aethoxy-acetanilid), acetauilid and methacetin 
(paramethoxy-acetanilid) have thus far alone been 
used in medicine, together with numerous known com- 
pounds of not ascertained value, indicate the boundless 
possibilities for the future in this direction. 

Acetal, ural, hypnone and somnal do not seem to 
me to have sufficient therapeutic value to justify 
their existence. Hyoscine and hyoscyamine have a 
limited range. Of the other hypnotics we must trust 
somewhat to experience in ascertaining which is least 
likely to disagree with a given patient ; and to one al- 
ready discouraged by long illness an unsuccessful trial 
of a new remedy may be so unsuccessful as to be disas- 
trous. Personally, I use them sparingly, and as indi- 
cated. There are cases where very large doses of 
powerful hypnotics must be used to produce sleep or 
else alcohol freely. On the other hand, most patients 
sleep better than they think and many sleep enough 
who believe that they sleep scarcely at all. 



A GYNECOLOGICAL CASE. 1 

BY W. S. EVERETT, M.D., HYDE PARK. 

On the second day of May, 1888, a young, very 
attractive and intelligent lady, hitherto a stranger, 
called at my office for advice and direction, if not 
treatment. Her look was anaimic ; her expression 
was troubled; her countenance was pale, colorless, 
like that of one who has been blanched from loss of 
blood. Her bowels were constipated, her appetite 
was poor. 

This is the history that she gave: Her general 
health had been fairly good in her childhood, aud 
until the menses appeared. Since that time, a strain 
of excitability or of depression had been worked into 
her history, that, accompanied by the disturbance of 
the menstrual molimen, had been the occasion of a 

1 Read at a meeting of the Dorchester Medical Club, May 1, 1890. 
17 Avers, Heinz, Hensner, Hinsberg, Rumptf. 



32 



BOSTON MEDICAL AND SURGICAL JOURNAL. [Jult 10, 1890. 



good deal of trouble, and had kept her quite frequently 
in the physician's care. 

She was twenty-three years of age. She had been 
in the care of one of our Norfolk County physicians 
in her earlier days, and he, it seems, not being quite 
satisfied with the results of treatment on general prin- 
ciples, had advised her to consult some specialist. 

Her troubles at this time were, according to her 
statement, a general prostration, which did not im- 
prove under tonic treatment, severe pains in the back, 
which, some two and a half or three years previous to 
the time of our interview, became transferred to the 
right hypogastric region where they had since re- 
mained, and had recurred at irregular intervals of from 
one to two weeks, from that time on, increasing in 
severity, until the anguish occasioned by them had 
become intolerable and had compelled her to seek 
relief. 

The catamenial flow came on when she was fourteen 
years of age, but had never been in any degree regu- 
lar, varying in times of its occurrence from six weeks 
to eight months. I do not find anything in my notes 
that enables me to say positively whether the intense 
suffering was relieved temporarily after the flow ap- 



peared, and I very much regret the omission. 

As a result of the advice of her former physician, 
she consulted a noted female physician of the city, 
who gave her " local treatment " as she said, which 
meant that she applied tincture of iodine to the mouth 
of the uterus, though she told her from the first that 
she did not find anything in particular to be wrong 
with her in that region. But these frequently recur- 
ring attacks of pain were not relieved, and she after- 
ward consulted another prominent practitioner of the 
city, who, after examination, referred all her troubles 
to disease of the ovaries, and advised their extirpation. 
For this measure she was not prepared, unless farther 
advice and different or, at least, corroborative counsel 
decided it to be imperative, and she consulted another 
leading physician of his time, who has since died. He 
advised strongly against the removal of the ovaries 
as matters then stood, and not making a positive diag- 
nosis of his own, referred her to an eminent specialist 
of the city, to whose office she had made some six or 
eight visits previous to calling at mine. 

He had made as thorough examinations as the case 
would admit at these interviews, and his investigations 
had been as exhaustive as he could make them, and he 
wrote to the physician, by whose advice she had con- 
sulted him, stating that he found the lower portion of 
the right kidney tender and manifestly diseased ; and 
accounted for the pain, that had come to be terrific in 
its violence whenever it recurred, by regarding it as a 
renal colic, for which, he said, the removal of the 
ovaries could be expected to do no good. 

She was married on the eleventh day of November, 
1 880, two days after the cessation of a menstrual 
period. The interval between that period and the last 
preceding period had been nearly four months, and its 
latest predecessor had been in the preceding February. 
It was, therefore, manifestly impossible for her to fix 
her wedding-day with any reference to that time, and 
it happened, as stated, just before her marriage, and 
terminated only two days before that event. Possibly 
the exhilarating excitement of preparation for that 
occasion may have been one of the predisposing causes 
that brought it on at that time, But it came, at all 
events, then, though she was not in the least troubled 



by the fear of what might happen, and did not look 
upon it as in any way an unfortunate circumstance 
that it should happen just as it did. 

Her next appearance occurred in October, 1887. 
Meanwhile she had supposed herself to be pregnant, 
but she did not expect to be eleven months about it, 
and she had not gone along otherwise just as she 
thought she ought to, if such were the case, and 
she consulted another physician, whose name, for some 
reason, she declined to disclose, who told her she was 
about three months along. When this period came 
on, in October, 1887, she flowed excessively, and suf- 
ferred much. In fact, her periods, whenever she did 
have them, were excessively painful and very profuse, 
being bright red blood at commencement, becoming 
more profuse as days went on, and finally ending with 
clots of considerable size and quantity, and in this par- 
ticular instance, disappointing all her hopes and mate- 
rially jeopardizing her prospects, whatever they might 
be, of ultimately rearing a family, and she was much 
inclined to yield to discouragement. 

After this period in 1887 had terminated, she again 
hoped that she might be likely to become a mother ; 
but, of course, she could not have become pregnant 
then, she thought, because the indications must have 
been unmistakable by the present time (May 2d) if she 
had done so. 

In February, 1888, the breasts became hardened 
and tender, and had remained so, growing constantly 
larger. The nipples, at this time of her visit (May 
2d), had also become more prominent than they had 
ever been, the areola? had become puffy in appearance 
and darker in color, and the follicles were very con- 
siderably enlarged. There was no examination, except 
of the breasts, at this interview, though the abdomen 
was felt through the clothing to be tense, firm and ap- 
parently much larger than in its ordinary condition. 

Such, now, is a description of my patient, and her 
present condition stated with as much accuracy as it is 
possible for me to give it. 

Here she sits in my office, on this May afternoon, 
and tells of all the suffering that she has experienced, 
tells also of all these various, yes, celebrated ones 
whom she has consulted within the last three years, 
of whom the first is committed to no statement of 
opinion, so far as is known, concerning the nature of 
her troubles ; the second, with large experience and 
extensive practice, had failed to find any indication of 
disease of any kind ; a third, eminent in his profession, 
had diagnosed disease of the ovaries, and advised their 
removal ; a fourth, had declined to make a diagnosis ; 
a fifth, still more eminent in his specialty, had found 
the right kidney diseased; and yet a sixth had pro- 
nounced for pregnancy at three months; she tells 
also of the yet unabated and frequently recurring 
paroxysms of intolerable suffering, tells of the unex- 
plained and extreme irregularity of the menses, and of 
her marriage. By personal observation also, she is 
found in the general unsatisfactory condition that has 
been described, with prominent abdomen, large and 
dark colored nipples, puffy areola?, with follicles en- 
larged, and with the history, as given, extending over 
all this period of years. 

It would have been a great comfort to me at this 
stage of our interview, if I could have excused myself 
for a moment from the presence of my patient, and, 
finding our club in convenient session within accessi- 
ble distance, have hurriedly laid my case before it 



Vol. CXXIir, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



33 



and asked what answer I should make to the woman 
when she asked me the question which she did ask 
uie, " What is the matter with me?" 

But there was nothing of the kind to come to my 
assistance, and I was obliged to rely on such resources 
as I had. And I saw nothing better to be done than 
to tell her that 1 could not expect to form an opinion 
concerning the cause of the suffering that she endured 
at a single interview when so varied opinions had 
been given by so many competent practitioners in the 
matter, and that as to the question of pregnancy, if a 
woman were herself in doubt in the early stages as to 
her condition, I could not, and did not have much con- 
fidence in the opinion of any who thought they could 
tell with any degree of certainty whether she were 
pregnant or not. 

But in view of the increasing size of the abdomen 
and the behavior of the breasts, I felt warranted in 
expressing the opinion that the probabilities pointed 
in the direction of her being in a family way. And 
here the interview ended. 

The next morning, May 3d, with very little regard 
evidently for the sanctity of the doctor's opinion, she 
sent me a note, stating that she had " come round" 
as she expressed it, emphasizing the words with a 
line drawn under them, and would like to have me 
visit her that day, which I did. She had been in 
doubt how to proceed. Whether it was best to try to 
promote a more copious flow ; or to try to stop it alto- 
gether, she did not know. 

She had feared that being in a family way, it might 
be a threatened miscarriage, and that the means that 
should promote it, might induce just what she was 
anxious to avoid. Yet if it was only an erratic or 
comet like return of what should be depended upon to 
come with regularity until there was good cause why 
it should stop, then there seemed to be no reason why 
it should not be encouraged in every way. I told her 
to promote it by every means, and gave such direction 
as seemed to be calculated to bring about that result. 
She went through that period regularly enough, and 
it turned out to be a regular period and nothing more, 
and the case stood precisely as it had stood for years. 

It is interesting in the progress of this case, to note 
the recurrence of the catemeuial flow, and I am able 
to give the times of its appearance with accuracy for 
the preceding four years. It came in March or April 
and in October, in 1884; that was when she was nine- 
teen years of age, and five years after commencing. It 
came in January and September, November and 
December, 1885 ; in February, July and November 6, 
1886, and she was married on the eleventh. The 
next and last appearance, previous to her visit at my 
office was October 11, 1887, just eleven months pre- 
cisely, from the day of her marriage. Ten times then 
it had appeared, when it should have come fifty. 
What could explain it ? what could be the cause ? I 
decided upon two things. First, that none of the old 
trails that had been worked thus far were ever going 
to lead up to an explanation of this condition in a 
young woman apparently otherwise in good health, 
and possessed of all the attributes that belong to a 
woman of her years. Second, that if mechanical ob- 
struction to the flow of the menses were present, it 
might furnish a more consistent explanation of all 
her experiences for all these years, than any theory 
that had yet been applied. One thing seemed pretty 
clear. The desire of her heart like all who begin to 



fear that the privilege of rearing a family is to be 
denied them, was set upon having children. It did 
not seem probable now as things looked, that it was 
likely to be gratified. She had been married now 
nearly two years, was married at a time when she 
thought immediate pregnancy was to be expected, had 
raised her hopes to the highest pitch of expectancy 
when the enlarging abdomen seemed to give evidence 
that her desires were likely to be fulfilled, and then 
after eleven months of uncertainty and anxious expec- 
tation they had been dashed out unceremoniously by 
the unwelcome return of October, 1887, to be again 
raised by the changes that had taken place in the 
breasts and nipples and areola;, aud the still increas- 
ing size of the abdomen, only to be stranded in hope- 
less despondency and disappointment by this last ap- 
pearance on the 3d of May. 

I determined to act upon the supposition that the 
menses were retained. It seemed reasonable to sup- 
pose that if the secretion took place regularly within 
the uterus and for any reason was not discharged, 
that the time would be likely to come when its pres- 
ence would cause pains that might be in the nature of 
uterine contractions, aud that would iucrease in sever- 
ity until they might answer the description given in 
this case, and that they might continue until they had 
so far overcome the obstruction to their free exit, 
whatever it might be, as to force out a portion of the 
confiued mass sufficient to afford relief, until the ac- 
cumulation had again become so great as to excite a 
recurrence of the pain, to be again relieved, only by 
the same means. And here it is that my notes would 
be so much more valuable, if I could say positively 
that the suffering was relieved for the time after the 
flow came on. But I have not the knowledge in my 
possession that justifies me in making that statement, 
though I believe it to be true. 

If this theory were correct I thought also it might 
explain why pregnancy did not occur. I determined 
to find an entrance into the uterus and to force one if 
necessary, though of course there was an opening, 
otherwise the menses could not by any possibility have 
been discharged, and Byford says that in many cases 
where the os externum was not larger than a small 
pin-hole patients have menstruated regularly without 
any pain whatever. Whether pregnancy is obstructed 
by such condition, he does not state. 

How should the operation be performed ? It did 
not seem to me that the sound was the best instrument 
for it as it would leave an opening smaller than it was 
desirable there should be, aud I feared to use either 
the knife, the scissors or dilators, fearing that I might 
set up an inflammatory action in the uterus of a 
woman of her nervous sanguine temperament, of which 
the end could not be foreseen. I finally decided to 
make use of a large silver probe with a very large 
bulbous extremity designed, I think, for probing gun- 
shot wounds of considerable depth, which would make 
a larger opening than the sound, without incurring 
the dangers of the tent, the scissors or the knife. 

I waited until the time came for the return of the 
period in June, and it did not appear, and it seemed 
useless to delay longer. The probe was forced 
through the external os, meeting with a good deal of 
resistance, but it was pushed onward as far as I dared 
to force it, meeting an increasing degree of resistance 
all the way. Finally I desisted, more because I did 
not dare to exercise the force necessary to carry it 



34 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 10, 1890. 



farther, than because the purpose of the operation had 
been accomplished, for of this I did not fee) at all sure. 

But I told her we would wait another month and 
see what happened. If necessary the operation could 
be repeated, perhaps more effectually. If it should 
not be necessary, we would all feel relieved. 

One point, at least was gained. I felt sure that 
whatever else might happen, we had no pregnancy to 
complicate the case. And I represented to her the 
advantage of abstaining absolutely from all the possi- 
bilities, whereby pregnancy could occur, until her 
status could be still more definitely determined ; tell- 
ing her that for our present purpose, the next best 
thing to knowing that she was in a family way was to 
know that she was not. 

There is every reason for believing that my injunc- 
tion was implicitly obeyed. She had begun to take 
courage in the prospect of a new departure, and was 
ready to aid my measures in whatever depended upon 
herself. 

But when the month came around, and I came to 
make my promised visit, I found the shutters up and 
the house closed. The family had disappeared. I 
supposed she had become disgusted either with the 
doctor or with his treatment, and had gone elsewhere 
to add another to the list of unsuccessful ones, into 
whose hands the fates had directed her steps, and I 
expected to see her no more. But one day, late in 
October, she reappeared to me and explained her 
absence and told of all that had happened since she 
had been away. It had seemed best, in order to carry 
out my wishes, that she and her husband should dwell 
apart for a time, and so, previous to my call in the 
early summer she had taken up her residence at the 
seashore, and the husband had provided himself with 
quarters elsewhere. Her June period she missed, but 
in July she came on regularly and on time and got 
through it more satisfactorily than for years. In 
August, to her great delight, she came on again regu- 
larly, and on the twenty-fifth of that month marital 
relations were resumed. 

Our case loses its interest from this time. No 
renal colic has since been reported ; the kidneys, both 
right and left, appear to be performing their function 
satisfactorily, and unless the ovaries shall yet develope 
some still more urgent symptoms, their extirpation 
will probably be indefinitely postponed, and the full 
measure of parental happiness reaches its climax in the 
circumstance that on the 12th day of June last, two 
hundred and ninety-two days after the family had been 
re-established, there came into the household a fine 
healthy boy that is the pride and the delight of all 
who take interest therein. 



i£epot:t£ of ^octetieg, 

AMERICAN LARYNGOLOGICAL ASSOCIATION. 1 
Dr. Charles H. Knight of New York, reported a 

CASK OK FIBROSA RCOMA OF THE RIGHT NASAL 
FOSSA, WITH UNUSUAL CLINICAL HISTORY, 

accompanied by a specimen. 

The growth in this case had its origin in the nasal 
cavity. Baker, forty-two years. Family and private 
health good. Twelve years previously he received a 

1 Report of the Twelfth Annual Congress, at Baltimore, Md. Con- 
cluded from page 14 of the Journal. 



blow upon the bridge of the nose, to which he attrib- 
uted his malady. For two years had had nasal ob- 
struction, gradually increasing; frequent sneezing; 
constant frontal headache. Disposition became irri- 
table, and used liquor to excess contrary to previous 
habit. No haemorrhage, until two months ago, when 
he expelled from the right anterior naris masses of 
bloody tissue, and about the same time expelled a 
fleshy mass as large as a robin's egg from the posterior 
nares. The right eye became closed by cedematous 
swelling of lids and infra-orbital region. The right 
nasal chamber was found completely rilled with a soft 
vascular and very sensitive mass resembling an old 
myxoma. Part of the growth was snared off, and 
profuse haemorrhage resulted. The growth was rap- 
idly reproduced in the next few days. 

The patient then went to the hospital, where Dr. 
Weir performed Chassaignac's operation. Part of the 
growth was curetted off, when it was found that it 
involved the ethmoidal and sphenoidal cells, and the 
operation was carried no further. The patient made 
a good recovery from the operation ; but the growth 
redeveloped in six weeks, and involved the face. 
Three months after the operation, the patient in a 
delirious condition, tore out a portion of the tumor by 
putting his fingers into his mouth and dragging out an 
irregular mass, which was from the naso-pharynx. 
The rush of blood was very great, but ceased sponta- 
neously before the arrival of the physician. The 
patient was exhausted, and died five hours later. No 
autopsy. 

The paper was largely devoted to a consideration 
of the literature of the subject, and the methods of 
operation. The lecturer favored a radical operation 
such as Maissouneuve's, when the growth shows any 
tendency to malignancy. The theory of traumatism 
was declared insufficient to cause the morbid action. 
It alone is not capable of creating malignancy. Mi- 
croscopic examination of the specimen showed the 
characters of fibro-myxoma. 

Dr. Bosworth deprecated severe measures. The 
only case of recovery from sarcoma that he knew of 
was one in which severe measures could not be borne. 
It was reported at the meeting of the American Medi- 
cal Association several years ago. Butlin says that 
it is at first a purely local disease. The old operations 
are unnecessary. At the present day all parts of the 
nose are accessible without such severe operations, 
and the growth can be snared off. In carcinoma no 
treatment is of service. 

Dr. Miilhall reported a case of small-celled sar- 
coma, filling both nostrils. The case also had some 
interest in connection with the question of the origin 
of the disease from injury. The man was injured on 
the railroad about a year before the disease appeared. 
When first seen, a mass of soft material projected 
from both nostrils ; it bled easily. The galvano-cau- 
tery was used to clear one nostril after several sit- 
tings ; but he become tired of treatment, took to the 
use of morphine, and died in four months. The dis- 
ease lasted about a year. 

Dr. Bosworth: The case is reported as one of 
libro-sarcoma. It would be interesting to know 
whether it changed in appearance at the time it took 
on malignant growth. 

Dr. Knight said, with regard to radical measures, 
lie would not advocate any except the operation of 
Maissonneuve. 



Vol. CXXIII, No. 2.] BOSTON MEDIO AL AND SURGICAL JOURNAL. 



35 



ADKNO II) TISSUK IN THE NASO-PIIARYNX AND Till? 
PHARYNX, A PRELIMINARY REPORT ON THE DE- 
VELOPMENT AND EARLY HISTORY, 

was the title of a communication read by Dr. II. L. 
Swain, of New Haven, Conn. 

The paper considered the adenoid tissue in this 
locality as a whole ; that is, the ring of tissue formed by 
the pharynx tonsil above ; next the tissue in the region 
of the tubes on either side, then the lateral columns 
of the pharynx, the faucial tonsils, and, last of all, the 
lingual tousil. This ring of tissue is right at the 
junction of the tissues formed by the extoderm and 
the entoderm of the embryo, and is itself formed by 
the participation of the entoderm as motive principle 
and the mesoderm as origin of the cell infiltration. 

In studying the development, it was found that the 
pharynx tousil was the earliest to begin, as it is the 
oldest gland iu the comparative history, being found 
in the lowest form of animals. Next in age were 
found the faucial tonsils; while the youngest member 
of the group, or at least the latest to form, was the 
lingual tonsil. Thus there is a physiological basis to 
observed phenomena of early atrophy of pharynx and 
late endurance of the lingual tousil. The beginning 
of all these different portions of the ring of adenoid 
tissue in the embryo was alike, not varying as does 
the tissue. The bursa pharyugea of Luschka seems to 
have a somewhat inconstant embryonic existence and 
must not be confounded with the recessus pharyngeus 
medius, which is a more frequent occurrence in the 
well-developed organ. 

The constant appearance of follicles in all parts of 
th is tissue is a normal phenomenon, but is, unquestiona- 
bly, as observed in the lingual tonsil, influenced by 
pathological changes. That is, disease favors an 
earlier appearance of the follicles, and makes an in- 
crease in their size and number. The conglobate 
glands in the pharynx tonsil possess no hollow spot. 

In considering the function of the adenoid tissue, 
many views were spoken of, but credence given to a 
two-fold purpose which this tissue fulfils, namely, an 
organ for the formation of leucocytes, which amoeboid 
cells, by virtue of their immigration to the surface, 
come into a position to meet micro organisms and pro- 
tect the system from their influence by destroying 
them. Secondly, there seems to be a direct relation 
between the number of leucocytes present in this 
adenoid tissue and the demand of the rest of the sys- 
tem for those cells ; for, in cases of long-continued 
purulent process, there is a great diminution in their 
number. From the first we may deduce reasons for 
the larger development of adenoid tissue in man and 
iu certain animals ; from the second, an explanation 
of the atrophy of this tissue in many observed 
cases. 

Dr. Bosworth complimented the author upon his 
paper, as the function and pathology of the lymphatic 
structures of the nose and throat are now occupying 
considerable attention. The suggestion by Scanes 
Spicer, that the tonsils are placed in the throat to 
absorb excess of fluid, does not amount to the dignity 
of a physiological theory. Killiau's view was that 
this adenoid tissue is placed here to destroy micro- 
organisms, but they might just as well be looked upon 
as traps for micro-organisms where they develop. 
A very interesting question in catarrh is, Where does 
all the fluid come from? 



Remarks were also made by Dr. Langmaid and 
the author of the paper. 

Dr. B. Fletcher Ingai.s, of Chicago, read a 

SUPPLEMENTAL REPORT ON CARTILAGINOUS TUMORS 
OK THE LARYNX AND WARTY GROWTHS IN THE 
NOSE. 

The first case had been reported to this Association 
two years ago, when still under treatment by applica- 
tions of chromic acid full strength for cartilaginous 
growths just beneath the vocal cords. Although a 
practical cure seemed to have been obtained, the pa- 
tient afterwards returned with slight thickening of the 
base of the growth, which required several subsequent 
applications. During the past year, there has been 
no recurrence. At present the mucous membrane 
appears healthy ; no cicatrix. The acid seems to have 
caused absorption rather than destruction. At the 
last meeting, a case of similar growth in the nose was 
reported, which resisted chromic acid, nitric acid, gal- 
vano-cautery and other means. Subsequent applica- 
tions of tincture of thuja occideutalis upon a pledget 
of cotton (twice daily) with internal administration of 
drachm doses three times each day, was followed by 
improvement. Occasional applications of chromic 
acid were also made about once a week. This was 
followed by complete disappearance of the warty 
growths. 

Dr. Bosworth referred to a case seen some months 
ago in a child three months of age. It was a broad, 
papillary growth on the tongue and palate. He ap- 
plied thuja, but without result. The growth was 
afterwards completely destroyed with acetic acid. 
They are like warts on the skin anywhere. 

Dr. Mclhall considered that some confusion 
existed between soft growths and papillomata. A 
paper published some time since stated that the writer 
had seen several hundred cases of warty growth. 
The diagnosis can only be made with the microscope. 
He had individually seen only a single case of papil- 
loma of the nose. It sprang from the anterior end of 
the middle turbinated bone, and looked exactly like a 
bunch of grapes. 

Dr. Jarvis advocated the use of chromic acid in 
removing papillomatous tissue, as the best caustic. 
He agreed with the last speaker that papilloma of the 
nose is rare ; he had seen only two cases. 

Dr. MacCoy had treated three cases of warty 
growths from the vestibule with the galvano-cautery. 

Dr. Mulhall said that he would have a micro- 
scopic examination made, and add it to the report of 
the case. 

Dr. S. O. Vander Poel, of New York, reported a 

CASE OF MYXOMA OF THE EPIGLOTTIS, 

and presented drawings of laryngoscopic appearances. 

The patient, a German, fifty-four years of age, a 
blacksmith, was well until seven months previous to 
coming under observation. He then had difficulty in 
deglutition and the sensation of a foreign body in the 
throat. No actual pain. Talking required effort, only 
occasional hoarseness, with feeble whispering voice. 
Suffocative attacks at night, waking suddenly from his 
sleep, owing to some mechanical obstruction. He lost 
flesh rapidly, owing, he thought, to the small amount 
of nourishment he had been able to take. Cough had 
been troublesome, and especial difficulty was experi- 
enced in removing mucus from the throat. Mitral 



36 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 10, 1890. 



cardiac murmur, bronchitis and emphysema were pres- 
ent. There was slight hypertrophic rhinitis, with 
ecchondroina of septum. With the laryngeal mirror, 
a growth of yellowish-red color, translucent, about as 
large as a horse-chestnut, was seen springing from the 
lingual side of the epiglottis ; surface glistening, lobu- 
lated and traversed by numerous small vessels. It 
was attached to glosso-epiglottic fissure of left side. 
It was so large as to prevent examination of larynx, 
only a small portion of vocal cords could be seen. The 
growth was removed with the galvanic ecraseur. 
The patient did not show much improvement after 
operation, but progressively failed, and died some four 
mouths later with all the appearances of leucocythemia. 
No malignant disease was discovered post mortem. The 
growth was a myxoma, and was attributed to the gen- 
eral disease, such growths being characteristic of leu- 
cocythemia. 

A review of the literature of the subject was ap- 
pended. 

The President remarked that, whereas the growth 
in the location described by the lecturer is rare, the 
same growths lower down in the pharynx are not very 
rare. He had seen a large number at Hyrtl's Clinic 
in Munich. 

Dr. Langmaid said that it was a new thought to 
him that these growths might be myxoma. 

Dr. Swain had removed from the fossa glosso-epi- 
glottideus a growth just at the junction of the epiglot- 
tis and tongue, which proved to be a simple polypus ; 
strictly a mucus polyp resernbliug those from the 
nose in every particular, except that it was more con- 
sistent. It did not contain lymphoid tissue. 

Dr. Vander Poel said that his remarks applied to 
a pure gelatinous growth characterized by stellate cells, 
with delicate processes interlacing, imbedded in a gela- 
tinous ground substance. He regarded Dr. Swain's 
case as analogous. 

The President remarked that such growths are 
most frequently fibro-sarcomatous in character. 

hoarseness and loss of voice caused by wrong 
vocal method, 

was the title of a paper by Dr. S. W. Langmaid, of 
Boston. 

The evils of unnatural and unphysiological methods 
of voice-traiuing pursued by some singing-masters was 
the chief topic considered, and especially, the forcible 
holding of the tongue down, during the formation of 
different tones. The idea that this gives increased 
room in the larynx and air-chambers is erroneous, on 
the contrary it interferes with the proper physiological 
action of the muscles which control the movements of 
the larynx and calls upon them to do two different 
duties at one time. One singer can get the best effects 
with the tongue flat, another will get her best results with 
the tongue partly raised. There is a great difference 
in the size and shape in different tongues ; the aim is 
to obtain the tone in the most natural manner in the 
individual. Cases were cited to show the effects of over- 
strain, temporary paresis, haemorrhage, etc. Treat- 
ment is rest and adoption of a natural method. 

This paper was discussed by Drs. Delavan, 
Hinkel, Mulhall, Mackenzie and Langmaid; 
and the conclusions as to the effects of wrong method 
and strain of voice concurred in generally and the 
treatment by rest and proper vocal gymnastics ap- 
proved. 



The afternoon session on the second day was opened 
by a paper on 

THE CONDITION KNOWN AS CHORDITIS TOBEROSA, 

read by Dr. Clarence E. Rice, of New York. 
The following conclusions were formulated : 

(1) That the condition known as chorditis tuberosa 
is not one of the pathological changes to be classed 
among those of chronic catarrhal laryngitis, but it is 
itself the primary lesion. 

(2) The presence of this nodule is the direct cause 
of the catarrhal changes in the larynx, which are de- 
veloped later. 

(3) This condition is almost always found in singers 
and public speakers, and is caused by a faulty method 
of using the voice; a callus occasioned by attrition 
of one band against the other. 

(4) Chorditis tuberosa occurs more frequently in 
women than men and is more often seen on the left 
than the right band. 

(5) A nodular enlargement will, in time, produce a 
similar change in the second band at the point of con- 
tact. 

(6) These nodules should be removed as early as 
possible. Singing should not be allowed until the 
bands are normal ; and faulty methods of using the 
voice should be proscribed. 

Drs. Westbrook, Daly, Delavan, Mackenzie 
and Rice discussed this communication. The opinions 
expressed were rather unfavorable to the results of 
treatment ; the supposition being that cases of ordinary 
chronic laryngitis are likely to be mistaken for " chor- 
ditis tuberosa," which is rare. 

Dr. Fletcher Ingals, of Chicago, read a paper on 

UNILATERAL PARALYSIS OF THE LATERAL CRICO- 
ARYTENOID MUSCLE. 

This is a comparatively rare condition, although bi- 
lateral paralysis of the adductors of the vocal cords is 
a common affection. Two cases are communicated in 
this paper, both following closely surgical operations 
in the mouth and naso-pharynx, and apparently hyster- 
ical, although possibly reflex. The usual symptoms 
of adductor paralysis were present. There were no 
other evidences of disease or of hysteria. The first, 
a school teacher, twenty-two years of age, recovered 
after a few weeks of mainly constitutional treatment. 
The second, a girl nineteen years of age, has been 
under treatment for about four weeks, without per- 
ceptible improvement. 

Dr. Bosworth noted one peculiarity of laryngeal 
paralysis. In several cases he had seen paralysis of 
one side of the larynx, with complete loss of voice, and 
in two instances, with production of falsetto voice. At 
the end of three or four weeks, the voice became 
almost absolutely normal, while the paralysis persisted ; 
the unaffected band having swung over to meet the 
paralyzed one, and so restored the voice. 

Dr. Frank Bosworth, of New York, reported 

A CASE OF UNILATERAL PARALYSIS OF THE ABDUC- 
TORS OF THE LARYNX ; THE RESULT OF AN AT- 
TACK OF BULBAR DISEASE; WITH UNUSUAL 
SYMPTOMS. 

A gentleman, who had chronic suppurative inflam- 
mation of left antrum following ulceration around a 
tooth which had been extracted nine months before 
coming under observation, gave the following history : 



Vol. CXXIII, No. 2.] BOSTON MJWWAL AND SURGICAL JOURNAL 



37 



He had an attack during the night of dizziness and 
nausea followed by right hemiplegia, with lateral loss 
of taste, and difliculty in deglutition. This attack 
passed away, and four months later, when seen, con- 
sidered himself completely recovered from the attack. 
No paralysis of extremities. Right vocal cord was 
motionless, however. This was due to some perma- 
nent change in the centre in the medulla governing the 
motions of the abductor muscle of the right side. A 
second case was referred to, which had been pro- 
nounced one of paralysis of left abductor, due to aneu- 
rism. Upon examination, a partial anchylosis of the 
crico-arytenoid was discovered, which fully accounted 
for the symptoms present. Here was a case pro- 
nounced one of paralysis by a very competent ob- 
server, and yet one which should not be regarded as 
either extrinsic, myopathic or any other form of 
paralysis. 

An inquiry from Dr. Westbrook if the sudden- 
ness of onset, and the extent of motor paralysis, and 
short duration would not exclude the medulla as the 
site of the lesion, and favor the view of embolism in- 
volving the capsule, brought the reply that there was 
no doubt in the reader's mind that the case was one 
of bulbar paralysis, which might have been due to a 
clot or some lesion involving the base of the brain or 
the cerebellum. 

The third day's session, held in the Library of the 
Johns Hopkins Hospital, began, at 11 a.m., with a 
paper by Dr. D. Bryson Delavan, of New York, 

ON THE EARLY DIAGNOSIS OF MALIGNANT DISEASE 
OF THE LARYNX. 

The lecturer dwelt upon the great importance of an 
early diagnosis of carcinoma, and the necessity of 
prompt recognition of the disease. The diagnosis in 
many cases is rendered difficult by complications. 
Thus, pulmonary phthisis may be in active progress, 
and lead to the diagnosis of tubercular laryngitis. The 
appearances of syphiloma of the larynx are often like 
those of cancer, and the temporary improvement, often 
seen under the influence of iodide of potassium, still 
further misleads the observer. On the other hand, 
syphilis of the larynx is often pronounced cancer, and 
serious operations advised. From a careful review, 
he believed that three points in diagnosis may be use- 
ful early in the case : 

(1) Thickening of the mucous membrane, with 
marked loss of motion in the neighborhood of such 
thickening, implies an infiltration of the muscles which, 
generally speaking, is due to malignant disease. An 
apparent paralysis of one side of the larynx, associated 
with thickening upon the same side, should always 
call for the exercise of extreme caution in the matter 
of prognosis. 

(2) As the result of numerous investigations made 
by many observers during the past two years, it is 
generally admitted that, of new growths of the larynx 
apparently papillomatous, those, the bases of which 
are not surrounded by a zone of inflammation, are 
probably benign ; while those which are encircled by 
a ring of reddened, inliltrated membrane are almost 
certain to be malignant. The truth of this proposition 
has been verified in several instances by the writer. 

Trans-illumination of the larynx, first suggested by 
Voltolini, has been studied during the past year by sev- 
eral observers. While by the use of the electric light, 
applied to the exterior of the larynx, the writer has 



found it possible to gain tolerably satisfactory results 
in causing the light to penetrate the walls of the lar- 
ynx, it would hardly be possible by this method to 
recognize the presence of an abnormal thickening, 
which was not already sulliciently well-developed, to be 
visible to the eye by the ordinary intra laryngeal 
demonstration* As a means of recognizing the pres- 
ence of a new growth of recent origin and of small 
extent, this method is, at present, of doubtful value. 
For the purpose, however, of demonstrating the rela- 
tive density of an enlargement of appreciable size, 
trans-illumination of the larynx is a method of consid- 
erable importance, and, even in cases of the class first 
mentioned, it may occasionally be found useful. 

Drs. Mackenzie, Daly, Ingals, Bosworth, 
holden, ascii, mulhall, swain, langmaid, 
iShiler and Delavan participated in a lengthy dis- 
cussion, in which there was little disposition to accept 
any diagnostic character of early carcinoma. Dr. 
Langmaid mentioned a zone of infiltration and redness 
of the tissue around the growth as an early indication 
of its malignant nature. The treatment was thoroughly 
discussed. 

A paper by Dr. Geo. W. Major entitled 

NOTES ON AN INTERESTING CASE OF ANEURISM, 

read by title, and referred for publication. 

Dr. John O. Roe, of Rochester, N. Y., reported 
and showed photographs of the post-mortem appear- 
ances of 

A CASE OF STRICTURE OF THE GSSOPHAGUS FROM 
INTERSTITIAL THICKENING OF ITS WALLS, 

which he considered a fibroid hypertrophy. 

The case was a women, fifty-eight years of age, free 
from syphilitic histor}^. The patient died from exhaus- 
tion. On post-mortem examination, anchylosis of the 
arytenoid articulations was found, which had been 
diagnosticated during life ; also a marked rigidity of 
the wall of the larynx due to general thickening of the 
tissues throughout the larynx. No indication of tuber- 
cle. Several constrictions were found in the oesopha- 
gus, only admitting a lead pencil by using force. 
Microscopic examination of the thickened walls showed 
a connective tissue infiltration, the muscular fibrillar 
being degenerated and replaced by this connective 
tissue formation. It was, therefore, a pseudo-hyper- 
trophy of the muscular wall, but a real hypertrophy of 
the connective tissue. The new formation was attri- 
buted to chronic inflammation analogous to that in the 
lungs in fibroid phthisis. 

Dr. Langmaid inquired if the lecturer had tried the 
introduction of a permanent tube in the oesophagus ? 

Dr. Roe : It was tried, but the patient could not 
endure it. 

Dr. Mulhall : Was anchylosis of crico-arytenoid 
articulation first detected post-mortem ? 

Dr. Roe : No, it was discovered by the laryngoscope 
during life. The patient spoke in a monotone without 
modulation of voice, same as in paralysis of the poste- 
rior crico-arytenoid muscle. 

Dr. Mulhall : Was there not paralysis? 

Dr. Roe : Yes, from pressure. 

Dr. Bosworth : There could not be a better illus- 
tration of the fact that all cases of immobility of por- 
tions of the larynx are not always due to paralysis ; 
here there was ankylosis. The pressure upon the 
recurrent laryngeal nerve had nothing to do with the 
paralysis. 



38 



BOSTON MEDICAL AND SU&G1CAL JOURNAL. [July 10, 1890. 



Dr. Rok stated that he had said that the anchylosis 
might have autedated the paralysis, but did not say 
that it had. 

Dr. Mulhall said that he had made two post- 
mortem examinations of malignant disease involving 
the recurrent laryngeal nerve, and in both cases the 
larynx was in the cadaveric position. In neither case 
was there the least anchylosis of the crico-arytenoid 
joint, although it had been immobilized for months. 
This is why he asked the question, Does Dr. Roe think 
that the anchylosis of this joint was the cause of the 
appearance in the larynx ? 

Dr. Roe : No. There was sufficient infiltration of 
tissues in the larynx to accouut for it. 

Dr. Mulhall inquired if he thought that an ab- 
ductor paralysis of eight or nine months, with very 
little motion, if any, in this joint, would produce anchy- 
losis ? 

Dr. Bos worth : A case was reported by Lefferts, 
in which, paralysis was due to a gumma ; months after- 
ward the gumma was absorbed, and the mobility of the 
joint was restored. Why should there be loss of 
motion? 

Dr. Roe: There was every evidence in this case, 
that there was complete paralysis of the larynx, so that 
this pressure upon the laryngeal nerve, and this infil- 
tration of tissue occurred before anchylosis took place. 
The paralysis of the posterior crico-arytenoid might 
have taken place first before complete paralysis. In 
another case with paralysis of both posterior crico- 
arytenoids ; and on post-mortem examination, the or- 
iginal cause was found to be a clot in the brain. 

Dr. Bos worth : It is an interesting communica- 
tion, and recalls the famous case of Mackenzie's. 

Dr. Mulhall: Was the patient iodized? 

Dr. Roe : Yes. She had been treated by iodide of 
potassium ; but when she came under observation, she 
was dying from exhaustion, and only lived a few days. 

A paper by Dr. F. Donaldson entitled 

THE LARYNGOLOGY OF TROUSSEAU AND HORACE 
GREEN, 

by request of the author, was read by title. 

In executive session, the following officers were 
elected for the ensuing year: W. C. Glasgow, M.D., 
of St. Louis, President ; J. O. Roe, M.D., of Rochester, 
Vice-President; J. H. Hartmau, M.D., of Baltimore, 
Second Vice-President; Charles H. Knight, M.D., of 
New York, Secretary and Treasurer ; Thomas R. 
French, M.D., of Brooklyn, N. Y., Librarian; Harri- 
son Allen, M.D.,of Philadelphia, Member of Council. 

The next place of meeting, Washington, D. C, with 
the triennial Congress of American Physicians, 1891. 



AMERICAN ASSOCIATION OF GKNITO-URIN- 
ARY SURGEONS.i 

SECOND DAY. JUNE 4TH, 1890. 

AFTERNOON SESSION. 
NOTES ON THE OPERATION, AFTER— TREATMENT, AND 
RESULTS OF L1THOLAPAXY, 

by Dr. G. Chismork, San Francisco, Cal. 

A MEMORANDUM IN A RARE COMPLICATION IN 
LITIIOLAPAXY, 

by Dr. .J. William White, Philadelphia, Pa. 

1 Report of the Fourth Annual Meeting, »t Altoona, Pa. Con- 
cluded (Tom page 17 of the Journal. 



Patient aged forty, weight 270 pounds, frequent 
urination, sometimes occasional sudden stoppage of 
stream in the act. Examination showed small stone 
in the bladder, moderately enlarged prostate, con- 
tracted meatus, hyperajsthetic urethra, granular and 
hyaline casts in urine. Patient etherized ; bladder 
washed out, four or five ounces of boric-acid solution 
left in. Lithotrite easily introduced ; the stone which 
was not over one-half inch in diameter caught, broken, 
and two of the fragments seized and further broken. 
On withdrawing the lithotrite, a gush of fluid followed 
the instrument. Attempting to insert a small, evacu- 
ating-tube, it was arrested at the prostate and would 
pass no further. All the instruments tried likewise 
failed. Forced injections of oil, urethral forceps, etc., 
were tried perseveringly. A large, blunt instrument 
was used in the effort of forcing this supposed frag- 
ment back into the bladder, but without avail. Finally, 
a small, Nelaton catheter passed into the bladder. 
For a few days considerable difficulty in urination ; 
smalluess, deviation of stream, and much tenesmus. 
On the fourth day, while straining, he ejected a uric- 
acid stone, after which urination was much easier and 
symptoms disappeared. Lithotrite again introduced, 
and a small fragment crushed. Patient in a few days 
returned home. 

Dr. W. K. Otis thought it a mistake to operate 
with cocaine. Bladders which had held a stone some 
time were exceedingly tender, and the continual strain- 
ing of the patient in the effort to expel the contents 
of the bladder made it difficult to operate. While 
cocaine dulled the sensation in the urethra, it did not 
dull the sensation in the bladder very much because 
the bladder was not very absorptive. In regard to 
Dr. White's case, he had seen that accident happen 
several times, but had finally succeeded in passing a 
smaller lithotrite. 

Dr. Bangs had only once had an impacted frag- 
ment like the one described by Dr. White. He called 
attention to one of the causes of failure of litholapaxy ; 
namely, when the stone was encysted. 

Dr. Cabot said the accident mentioned by Dr. 
White had not occurred in his experience, but he had 
seen it occur, in one case with fatal result. Dr. Chis- 
more spoke of the difficulty of getting the last frag- 
ment or getting the stone at all in some cases where 
there was a pocket behind the prostate. In the ex- 
treme case described that might be possible. He had 
found where the pocket was of less importance than 
in that case, the position of the patient to help very 
materially in getting the stone. By raising the hips 
so as to roll the stone back from the prostate to the 
fundus of the bladder, one could often easily reach 
a stone which before was inaccessible. He had 
several times used Dr. Chismore's suction lithotrite, 
and bad found it of value in searching for a fragment 
he had failed to seize with the lithotrite. 

Dr. Bryson was surprised that no mention had 
been made of the use of the cystoscope in a case 
where there was doubt as to whether a fragment 
still remained. He thought by the use of it a good 
deal could be told about the pockets in the bladder, 
unless there was considerable bleeding. Dr. Bryson 
mentioned an experience similar to the one Dr. White 
had had. He had oftentimes been embarrassed in the 
removal of fragments with any apparatus owing to the 
thickness and toughness of the mucus in which these 
fragments of secondary calculi were often imbedded. 



Voi,. CXXTII, No. 2.] BOSTON MEDICAL A 



ND SURG I d Ah JOURNAL. 



30 



A mixture of bicarbonate of sodium would dissolve 
the mucus better than anything else he knew of. 

A CASK OF CYST Or THE KIDNEY APPARENTLY CURED 
BY A SINGLE ASPIRATION, 

by Dr. A. T. Cabot, Boston. 

Dr. J. W. White was not aware that authorities 
were so positively in favor of nephrectomy under 
such circumstances. It never would have occurred to 
him in a simple case of hydronephrosis or simple cyst 
of the kidney to do nephrectomy without first trying 
the effects of nephrotomy. Statistics showed that 
nephrectomies after nephrotomies were less fatal than 
primary nephrectomies. 

Dr. Bryson agreed with Dr. White that it would 
not occur to him to do a nephrectomy first under such 
circumstances. He thought that in every case there 
was ample time for drainage. He did not think the 
danger to the general health was sufficiently severe to 
warrant measures being taken with any degree of 
speed. 

PERIPHERAL NEURITIS OF SYPHILITIC ORIGIN, 

by Dr. J. A. Fordyce, New York. 

The writer spoke of the infrequency with which in- 
flammation of the peripheral nerves was encountered 
in syphilis, and reported two cases which had come 
under his observation. In one patient four months 
after infection, a paralysis of the facial nerve occurred, 
involving both the eye and the mouth muscles, and 
slightly impairing the sense of taste on the paralysed 
side. The paralysis disappeared at the end of two 
weeks under antisyphilitic treatment. 

In the second case reported, a multiple neuritis of 
the lower extremities appeared with the outbreak of 
the early secondary eruption. The affection was 
characterized by paresis of the lower extremities, in- 
ability of the patient to walk or stand erect, loss of 
the patellar tendon reflexes, muscular tenderness, and 
numbness of the feet and lower one-third of the legs. 
Electrical examination showed loss of excitability of 
the nerves, and partial reaction of degeneration in the 
muscles, together with muscular atrophy. The func- 
tions of the bladder and rectum were unimpaired. The 
patient recovered the use of his lower extremities 
under the use of mercurial inunctions and iodide of 
potassium. 

A CONTRIBUTION TO THE STUDY OF MULTIPLE NEURI- 
TIS OF SYPHILITIC ORIGIN, 

by R. W. Taylor, New York. 

Dr. Post said that Dr. Taylor's last remark in re- 
gard to the evanescence of the analgesia brought to 
his mind a case of his in which a gentleman who has 
had syphilis of some ten years' duration has on one 
thigh an analgesic spot which has existed since a very 
early time in his syphilis, and has not changed from 
the first. There certainly could be no hysteria in that 
case. 

Dr. R. W. Taylor said there was one point he 
had not elaborated as yet ; namely, that frictions of 
mercurial ointment caused subsidence of the swellings 
and disappearance of the pain. He thought the affec- 
tion might be summed up in this way : that it was a 
process analogous to that which goes on in the fibrous 
tissues of the joints, which was inflammatory and 
hyperplastic and produced those arthralgias, that is, a 
simple, inflammatory process taking place in the con- 
nective tissues of the nerve, irritating that and caus- 



ing pain, or being of a less hyperplastic, less inflam- 
matory character, and going on to the degeneration of 
the nerve. 

DIPHTHERIA OF THE MEATUS URINARIl.S. 

by Dr. F. Tilden Brown, New York. 

Young man, nineteen ; healthy. Dirty household 
cotton used by the patient to cover the glans. In- 
fection rapidly developed within thirty-six hours. 
When next seen, presented a raised-up, wax-like for- 
mation over the meatus, which microscopically showed 
cocci, diplococci, streptococci, besides three varieties 
of bacilli. For the next three days, newly formed 
caps were removed with increasing difficulty. Finally, 
necrotic action resulted in the loss of the tip of the 
glans and contraction of the meatus. Constitutional 
symptoms slight, but pretty clearly brought out by 
the advent, short continuance, total disappearance of 
albuminuria, with certain renal elements shown micro- 
scopically. Recoverj complete, without extension of 
diphtheritic process along the urinary tract. 

Dr. Taylor had seen many such cases following 
circumcision, particularly in those who lived in squalor 
and poverty. The glans penis was attacked with red- 
ness of an exudative character, and was promptly 
covered over with this dirty-colored membrane, which 
in its first stages had the appearance of tallow. As 
that increased, it dried into this tough, brownish-white 
membrane. He had seen the same diphtheritic condi- 
tion on the healing surface of chancres. 

a case of extrophy of the bladder (with 
photographs), 

by Dr. A. T. Cabot, Boston. 

Boy of five; well-nourished. Congenital extrophy 
of the bladder and epispadias ; defect in anterior 
abdominal wall perhaps three-fourths of an inch in 
diameter ; and, as usual, the whole upper wall of 
urethra wanting. Abdominal wall lax. Decided to 
operate by parting the skin at a short distance around 
the defect, and then bringing it together with sutures, 
so that the under surface of the fold thus formed 
should be the anterior wall of the bladder. Operation, 
July, 1889. The epithelial covering of the surface 
immediately around the opening was very thin and 
closely attached to the tissues beneath. A line about 
one-half an inch wide was denuded at a sufficient 
distance from the edge of where the tissues were lax 
and could slide easily on the underlying parts. The 
only place where there was any difficulty in bringing 
the sides together was at the upper angle, where there 
was considerable scar-like tissue, the remains of the 
umbilical scar. This upper portion which came to- 
gether hard, failed of union ; but all of the lower part 
bealed by first intention, and formed a bridge over the 
opening in the abdominal wall which prevented any 
considerable prolapse of the bladder mucous mem- 
brane. The opening between this bridge and the 
upper surface of the penis was so close that the escape 
of urine was much interfered with, and in consequence 
a considerable hydronephrosis formed ; and during 
this time the boy became very weak and pale, and the 
amount of urine was considerably diminished. October 
22d, second operation for providing a more free escape 
of urine. Body of penis removed; mucous mem- 
brane of urethra dissected off, and united to prepuce. 
Urine escaped much more freely. Boy rapidly re- 
covered. 



40 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 10, 1890. 



Dr. Bryson said that in case of deformities of the 
lower genital or urinary organs, we were apt to find 
deformities elsewhere, that is, hypospadias or un- 
descended testicle, as a rule, indicated that there were 
other deformities, and he had wondered if that could 
possibly have anything to do with hydronephrosis. 

Dr. Cabot stated that the hydronephrotic condi- 
tion came on very slowly. 

A .METHOD OF EMPLOYING ANTISEPSIS IN RECENT 
ANTERIOR URETHRITIS, 

by Dr. J. W. White, Philadelphia, Pa. 

Dr. White had used salol combined with cubebs and 
copaiba in tablets in about ninety cases of gonorrhoea. 
These cases were not selected, but were taken as they 
presented themselves. The amount of salol given 
was at first about four grains, six times a day. Later, 
the amount was increased. This treatment seemed to 
him to yield better results than cubebs and copaiba alone 
and indeed better than any form of treatment hitherto 
used by him. He merely wished to state his impres- 
sion of the value of salol in gonorrhoea after a limited 
experience both in respect to time and number of 
cases. 

Dr. R. W. Taylor said the ouly tangible evidence 
that the gonococcus was the etiological factor in 
gonorrhoea rested upon the experiment of Bumm, 
who had inoculated the urethra of a woman with the 
twentieth culture of the gonococcus, and produced the 
disease ; but the details of the environment of the case 
were not such as to make it certain that the gonor- 
rhoea arose in its way. He did not deny that gonorrhoea 
might be the result of the gonococcus, but there was 
no proof of it other than that cited. The micro-or- 
ganism theory was elusive in practice. He had found 
no good at all from retro-injections, or from injections 
of bichloride of mercury, in gonorrhoea. He did not 
think one could draw definite conclusions as to the 
efficacy of salol in this disease, so long as it was used 
in combination with other drugs like cubebs and co- 
paiba. Time was also a very important element in 
testing a drug. 

Dr. Belfield thought Dr. White had taken a 
very rational position in the matter. In estimating 
the value of auy drug in the treatment of gonorrhoea, 
we must bear in mind that the disease is often very 
closely simulated by something which is not gonorrhoea. 
A man who had had gonorrhoea might have an out- 
break which closely resembled the genuine outbreak; 
and the clinical course of this would be much more 
favorable, whatever the therapeutics employed, than 
in case of a fresh infection of a virgin urethra. He 
believed gonorrhoea to be a parasitic disease, yet all 
the remedies which destroyed parasites had been un- 
availing in his hands, and he employed the purely em- 
pirical treatment of hydrastis locally, and an alkali. 
He had had no experience with the combination used by 
Dr. White. The fact that in any given urethra about 
one-half of the lacuna; opened backward was, as Dr. 
White had suggested, an important factor in the per- 
sistence and recurrence of gonorrhoea. The lacuna; 
which opened backward formed a nidus for the recep- 
tion of gonorrhoea] poison. 

Dr. F. T. Brown said he was so thoroughly satis- 
fied as to the position of Neisser, that he did all his 
work on the presumption that his statements were 
going to hold good. He had relied upon the Lafay- 
ette mixture, with the employment locally of bichlo- 



ride retro-injections (1-30,000 to 1-15,000). After a 
week's use, he had generally combined a weak solu- 
tiou of nitrate of silver (1-1,000 or 1-2,000). 

Dr. J. B. White agreed with Dr. Taylor, that a 
specific cause of gonorrhoea was not proven, yet he 
thought the preponderance of evidence was to the 
effect that gonorrhoea was a specific disease. He had 
not seen satisfactory results from deep urethral injec- 
tions. He had sometimes seen considerable urethro- 
vesical irritation occasioned by it. He had not had 
satisfactory results from the use of the bichloride so- 
lution, either in the mild or strong solution. He had 
obtained better results from simply washing out the 
urethra with warm water, and then injecting a mild 
hot solution of sulphate of zinc. As a rule, he did 
not give any internal treatment unless the symptoms 
required it. 

Dr. J. A. Fordyce had used in 150 or 200 out- 
patients of the Bellevue Hospital a solution of nitrate 
of silver, about 1 to 4,000. This gave rise in some 
cases to bloody urine ; in others, to great pain in 
urination, so that treatment had to be suspended or 
the solution made weaker. In some cases in which 
the nitrate of silver caused much pain, he gave the 
Lafayette mixture internally. He thought he got 
better results from this solution than from the ordin- 
ary injections, and felt disposed to continue its use. 

Dr. Post thought, in testing new remedies, first 
cases of gonorrhoea were the ouly ones that should be 
considered. He was surprised that so little value 
had been placed on the oil of sandalwood which he 
regarded the best of antiblenorrhagics. It certainly 
was equal in efficacy upon the gonorrhoea with copaiba, 
and much less likely to overturn the stomach. His 
favorite injection was a very dilute solution of bichlo- 
ride of mercury. He did not use injections during the 
acute, inflammatory stage. 

Dr. W. K. Otis thought salol, if efficacious, a par- 
ticularly good remedy, because, while giving that, it 
would not be necessary to give injections. If one 
believed in the gonococcus, one would not give injec- 
tions in the acute stage, because the gonococcus was 
then out of the reach of injections, and one also took 
the risk of causing a posterior urethritis by washing 
the pus down the urethra. In case of fresh gonor- 
rhoea, he thought recovery in six weeks was doing 
well. He was using injections of the nitrate of silver. 
Patients bore it well, as strong as I to 1,000. 

Dr. D. R. Palmer believed in the gonococcus and 
in the antiseptic treatment of gonorrhoea. He had 
had some very favorable experience in the matter of 
irrigation. This he applied with the culver nozzle 
rather thau with the catheter. He believed we had 
had introduced all the medicameuts that could possibly 
be of any benefit in the way of direct local applica- 
tion, and that the solutiou of the problem lay largely 
in internal medication. There had been an era of in- 
ternal medication in the past, but that was a blind one 
compared to this. There were the same objections to 
internal treatment as to local treatment: the remedies 
used were liable to cause disturbance. Salol did not 
disturb the stomach, and should be given up to fifteen 
grains three times a day. He was surprised to hear 
the statements as to the strength of nitrate of silver 
solutions used. He began, in acute cases, with a little 
citrate of potash internally, and hot applications. As 
soon as it could be borne, he used bichloride of mer- 
cury, the strength of the wash being determined by 



Vol. CXXIII, No. 2.] BOSTON MEDWJL AND SURGICAL JOURNAL. 



41 



the sensitiveness of the urethra. A four per cent, 
solution of cocaine would relieve the sensitiveness, it' it 
were great. He used the boric-acid injection for its 
soothing effect. In the stage of decline he used an 
injection of nitrate of silver, five to seven and one- 
half grains to the ounce. This injection was carried 
down fully six inches by means of the long solid-silver 
nozzle. If the patient complained of pain, he used 
cocaine. Such injections were given two or three 
times a week. Sometimes hot, boric-acid injections 
were used after them, and the patient was allowed to 
use at home any of the old injections. In short, he 
attempted to fight the disease " horse, foot and dra- 
goons"; care being observed not to set up inflammatory 
trouble and tumefaction. 

Dr. Glenn said that during the last five years he 
had obtained good results from the use of weak, non- 
irritating injections of chloride and iodide of zinc, — 
iodide of zinc ten grains, chloride of zinc three grains, 
water six ounces, long syringe with good nozzle. He 
used it at any stage that the patient would endure it. 

Dr. L. B. Bangs said he had no routine treatment, 
lie tried to overcome hyperaemia by rest in bed. He 
did not use bichloride injections. If he used bichlo- 
ride irrigations it was to secure good drainage and 
soothe the mucous membrane. 

Dr. J. P. Bryson alluded to a paper written by 
Dr. Bryan and himself, which was based on the ob- 
servation of 1,394 cases of gonorrhoea observed toler- 
ably carefully at the clinique. It gave the amplest 
possible clinical confirmation of the specificity of 
gonorrhoea and also of the assertion that the micro- 
coccus of Neisser was the specific element in the pro- 
duction of the disease. The paper dwelt also upon 
two points connected with the internal administration 
of remedies: (1) the sterilization of the urine ; (2) all 
those remedies which acted through the urine also 
acted, and, as he thought, more directly and thor- 
oughly upon the gouococcus through the blood. His 
opinions were fully expressed in that paper, and had 
not in any way changed. 

Dr. J. W. White said that he had seen exceeding 
severe irritation set up by an injection of nitrate of 
silver as strong as five to seven grains to the ounce of 
water, and also that he was afraid of urethral injec- 
tions of cocaine. 



AMERICAN NEUROLOGICAL ASSOCIATION. 

The Sixteenth Annual Meeting was held in the 
Hall of the College of Physicians, Philadelphia, June 
4, 5 and 6, 1890. 

The President, Dr. E. C. Spitzka, on calling the 
meeting to order for the business of the opening session 
said that though there might have beeu in the history 
of the society a period when it had devolved upon the 
presiding officer to fill gaps in the programme, this 
was no longer the case ; and with such a plethora of 
scientific papers as confronted them, communications 
by the President might well, at this stage be omitted. 
He should like to thank the local neurological society 
for its courtesy and exertions on behalf of the national 
body. He would call attention to a very beautiful 
specimen of 

MULTIPLE THROMBI OF THE CIRCLE OF WILLIS, 

prepared for their inspection. The patient from 
whom this was taken had been attacked by incomplete 



left hemiplegia. The facial portion had remained 
stationary while the rest had improved. Then there 
had been another attack, involving the other side with 
paresthesia and pain. The case had terminated in 
coma and death soon after the second seizure. 

UNUSUAL FORMS OF CHOREA, POSSIBLY OF SPINAL 
ORIGIN. 

This was the title of a joint communication by Drs. 
S. Weir Mitchell, and ('. W. Burr. 

The first case described was one of inherited, con- 
genital chorea, possibly involving the spinal cord. 
The patient, a young man eighteen years of age, had 
presented himself at Dr. Mitchell's clinic in 1889, 
complaining of constant, involuntary movements of 
the legs, arms and head. The history of the patient's 
family was of special interest in this case. 

His maternal grandmother had suffered from chorea 
for many years, not from birth ; but she had while so 
affected given birth to the patient's mother, who was 
choreic from birth till death. Both the patient's 
parents had died of phthisis. There was no history 
of other cases of chorea or any nervous disease in the 
family. The patient's choreic movements had begun 
in early infancy, probably from birth, and as a child 
he was puny, and of tardy development. His present 
condition was that of a fairly built young man, of 
good strength, weighing one hundred and thirty pounds, 
and other than the condition immediately associated 
with the chorea, there was no physiological disturb- 
ance. Knee-jerk was increased on both sides, and the 
cremasteric, sole and abdominal reflexes were marked ; 
ankle clonus was occasionally present, aud at times 
rigidity at the knee, the feet being then turned in- 
ward at the ankle. All the conditions were increased 
by motion, and the administration of moderate doses 
of strychnia. Sensation to touch, pain and tempera- 
ture were normal, and so was station. While awake 
the patient's entire voluntary muscular system was 
more or less in action. Sudden presence of a stranger 
emphasized the trouble. During sleep there was per- 
fect quiet. No spinal tenderness existed ; urine was 
normal ; and so, with some slight muscular insuffi- 
ciency excepted, was vision. 

Dr. Mitchell then read in detail two other cases, 
in which the patients were brothers, their father hav- 
ing at forty-five years of age developed alleged choreic 
symptoms. The first of these two cases had resembled 
in general aspect canine chorea. 

The authors of the paper thought the first of the 
series of three cases in which the disease had run 
through three generations, extremely rare aud that 
organic changes were present somewhere in the motor 
tract of the patient might, they thought, be admitted, 
because of the extreme chronicity of the affection, its 
resistance to all treatment, and the presence of very 
distinct ankle-clonus and rigidity, these latter symp- 
toms pointing to involvement of the cord. Whether 
the changes were confined to the cord it was more 
difficult to say. It was not wished to do more than in- 
dicate the spine as possibly implicated in all the cases. 

Dr. C. L. Dana, said he thought the view taken 
by Dr. Mitchell, as to the relation of heredity in 
chorea was the correct one. 

Dr. Sachs, suggested that some of the features 
Dr. Mitchell had mentioned in detailing his cases of 
chorea resembled somewhat the peculiar disorders of 
movement noticed in children with spastic palsies. 



42 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 10, 1890. 



Some of these conditions appeared at a late date, 
and might be either mild or severe in character. 

Dr. Mitchell said the view he had advanced was 
rather an hypothesis than a theory. 

Dr. Sachs said that he had seen these peculiar 
disorders present after every trace of the early paraly- 
sis had disappeared. In two of the cases cited, the 
patient had shown exaggerated reflexes which were 
also found iD the congenital case, it was possible that 
one or other of the cases might be congenital palsy, 
in which the symptoms of palsy had disappeared. He 
could not abandon the idea that some of the cases de- 
scribed might show changes in some part of the brain. 

Dr. E. D. Fisher stated that he had seen a great 
many such cases as Dr. Sachs had referred to. In the 
almshouse they had both adults and children whose 
history was that of congenital paraplegia or hemi- 
plegia of cerebral origin, and in which the paralyses 
were associated with well-marked choreic movements. 
It had seemed to the speaker that many of these cases 
where the condition had remained chronic for so long 
a time, were really not of the nature of ordinary 
chorea, which was a self-limited disease. He had 
always regarded these conditions as associated with 
sclerosis, leading to degeneration in the nerve-cells 
and nerve-fibres, and to descending degeneration in 
the cord. He had looked upon this as of cerebral 
origin, because it was found that the mental powers, 
though not greatly affected, showed some duluess, 
especially in the acquisition of knowledge. 

Dr. F. X. Dercum thought it was not at all im- 
probable that a spinal centre might be affected. No 
doubt there was a form which was purely spinal. 

Dr. Weir Mitchell said that many years ago he 
had stated his belief that ordinary chorea should be 
classified into three distinct groups. It was true that 
cerebral changes could arise in these choreic condi- 
tions, but h was rare to see these conditions affecting 
both sides, no matter what the changes were in the 
brain. Trouble in both lower extremities was espe- 
cially rare; therefore the first case alluded to was not 
choreic, resulting originally from paralytic conditions 
accompanied by descending degeneration of the cord. 

DOUBLE CONSCIOUSNESS. 

Dr. Mitchell then alluded to the notorious case 
of Ansell Brown, who had left his home, assumed 
another name, and, as asserted, had lived for some 
time without knowledge of his previous existence. 
On regaining control of his proper identity, he had re- 
turned home. Hypnotism had been recently tried 
upon him, and while under its influence the man's 
mind could be made to revert to incidents in his ficti- 
tious existence, while of his real identity he would 
then know nothing. 

Dr. Knapp cited a case of hystero-epilepsy, in 
which there were decided spells of changed conscious- 
ness. As to the question of spinal chorea, he was 
struck with the analogy of Sydenham's chorea with 
the conditions of ataxia, tonic spasm and associated 
movements of which he had recorded several cases, 
and to which some of these cases of chorea bore strik- 
ing resemblance. It did not seem, however, that we 
were yet in a position to assume any oue of these mo- 
tor disturbances as having focal significance. They 
might have their origin anywhere within the motor 
tract, and he hoped to show that tumors were not un- 
frequently the cause. 



THE WEATHER IN RELATION TO NEURALGIC PAIN. 

Dr. Mitchell had had an intelligent patient of 
his, who was a great sufferer from neuralgic attacks, 
make elaborate studies and observations of the effect 
of variations of the weather upon the paroxysms. 
Briefly stated, the scientific findings were that the 
maximum of pain bore direct proportion to the pre- 
valence of storms, and that the Aurora was a certain 
precursor of neuralgic exacerbation. 

CHRONIC SOFTENING OF THE CORD. — SENILE PARA- 
PLEGIA. 

Dr. C. L. Dana, of New York, read a paper on this 
subject, narrating a case which, he said, established 
upon a firm foundation, for the first time, the fact that 
in the gray matter of the cord, there might exist pro- 
gressive softening from obliterating arteritis, just as 
found in the brain. It also established the pathology 
of senile paraplegia, no convincing evidence as to the 
nature of which had, until recently, been adduced. 
The question of non-inflammatory softening of the 
cord had been but obscurely dealt with, or let entirely 
alone. Acute softening had been described usually as 
synonymous with acute myelitis, but the term was 
wrongly used, and should not be applied to inflam- 
matory processes at all. It had of late been suggested 
that some of the cases of acute myelitis were, in fact, 
primarily necrotic processes, but evidence was lacking 
in substantiation. The case he would describe was not 
of the acute type, but was a chronic myelomalacia. 

The patient, an old man of seventy years of age, of 
whose early life little could be elicited, except that he 
had been generally healthy, had, about four years ago, 
noticed some weakness of the legs. There was no 
pain. The condition had progressed, until one year 
ago there was complete disability to walk, incontinence 
of urine, and trouble with the rectal sphincters. When 
seen in 1889, the man hart presented the characteristic 
appearances of senility. The symptoms of the disease 
were limited to the lower extremities, which were 
wasted and contractured, and knee-jerks were goue, 
there was no clonus or trepidation. Sensation was 
everywhere normal, indeed the condition was rather 
that of hyperesthesia. No pains in the legs, girdle 
pains or bedsores. Up to the time of the patient's 
death, which had resulted immediately from exhaus- 
tion, the general symptoms had changed but little. 
The mind was clear, though senile. The only gross 
changes in the cord or membranes was noticed in 
the anterior horns in the sections taken low down. 
The more minute examination of microscopical sec- 
tions had demonstrated the case as one of degenerative 
endarteritis with sclerosis, obliteration of the vessels, 
causing the softening of the anterior horns and inter- 
mediate gray matter. This process was accompanied 
by secondary congestion, dilatation of small vessels and 
capillaries, but no haemorrhages. The condition was 
one of softening of the cord precisely analogous to the 
so-called softening of the brain. It was not inflamma- 
tory, and could not be termed an anterior polio-mye- 
litis. It was not cell atrophy, and dirt not belong to 
the spinal forms of progressive muscular atrophy. 
While the change was, without doubt, largely a senile 
one, the cord did not correspond to the description of 
such conditions given by Leyden. The disease might 
be called a senile paraplegia from softening of the an- 
terior horns due to obliterating arteritis. 

( To be continued.) 



Vol. CXXHI, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



43 



THE BOSTON 

jHeMcal and ^uvgtcal goimtal. 



Thursday, July io, 1890. 



A Journal of Medicine, Surgery, and Allied Sciences, published at 
Boston, weekly, by the undersigned. 

SunscRH-rioN TERMS : $5.00 per year, in advance, postage paid, 
for the United States, Canada and Mexico; $6.56 per year for all for- 
eign countries belonging to the Postal Union. 

All communications for the Editor, and all books for review, should 
be addressed to the Editor of the Boston Medical and Surgical Journal, 
283 Washington Street, Boston. 

All letters containing business communications, or referring to the 
publication, subscription, or advertising department of this Journal, 
should be addressed to the undersigned. 

Remittances should be made by money-order, draft or registered 
letter, payable to 

DAMKELL & UPHAM, 
283 Washington Street, Boston, Mass. 



THE COUNTRY DOCTOR. 

Wonder has often been expressed that the country 
doctor — and we make this remark knowing that there 
are illustrious exceptions — has not done more to ad- 
vance medicine. He writes but little, makes few orig- 
inal investigations, and now that preliminary study 
with a preceptor, is growing less and less acceptable 
to medical schools, influences slightly professional 
opinion. We allude particularly (and we wish in what 
we say to be so understood) to the practitioner whose 
home is far from the metropolis, the medical school 
and hospital, who seldom finds time to get away for a 
day's vacation to attend clinics, witness a major opera- 
tion, or even be present at an important medical meet- 
ing. He possibly takes one medical journal, or he 
may long since have given this up, " not having time 
to read it." He has frequent cases which he has 
carefully followed to their termination, and where he 
has been generously granted an autopsy ; these cases, 
which would be instructive if reported, he has never 
written out ; in fact, writing is irksome to him, and 
he has no incentive to contribute new data to science. 
It has not been his custom to take daily notes of his 
cases. He makes few changes in his practice, except 
as occasionally a consultation with some younger phy- 
sician, fresh from clinics and hospital work, reminds 
him that methods and manners are changing. Now 
and then some old professor from the great Hospital 
Medical School comes into his section of the country 
for recreation, for hunting or fishing, and " posts him 
up " as to modern methods. 

The country physician is both conservative and 
cautious. He is very shy of the new remedies. He 
would not dare to open the knee-joint antiseptically 
and drain it for a traumatic arthritis, much less perform 
a resection, or laparotomy; if those operations are re- 
quired, his metropolitan brother must be summoned. 
This timidity is not to be wondered at, it is so seldom 
that he sees cases requiring peculiar surgical skill. 
An ordinary amputation he does not fear ; he gives 
his anaesthetic and goes to work with a farm-hand for 



his assistant; he makes his flaps secundum urtem, dex- 
terously takes up and ligatures the arteries, and puts 
on the dressing; thanks to healthy surroundings and 
good air, the operation is a success though done without 
antiseptics. As for the treatment of fractures, with 
his extemporized splints of clapboard, sole leather or 
glue, he claims as good results as his city brother. And 
it is an open question whether the city brethren could 
do as well if placed in the same circumstances. 

In regard to the pharmaceutical part of his work, he 
labors under some disadvantages. There may be no 
apothecary in the village where he lives and he is 
obliged to furnish medicines. Consequently he must 
carry ample supplies with him of tinct. ferri chloridi, 
pot. nitras., pulv. Doveri, quinice sulphas, tinctura 
digitalis, and various cathartics, diaphoretics and tonics. 
He has not been " pestered " (we use a term which is 
current among certain urban medical practitioners) 
with visits by the pharmaceutical travelling agents with 
their handsome gelatine-coated pills, their tablet tri- 
turates, and their " parvules," consequently the few 
remedies which he carries are in a rather crude shape. 

The country doctor is still somewhat old-fashioned 
in his therapeutics. He does not hesitate to give tar- 
tarized antimony in colds and fevers (though in very 
small doses), but he has long siuce given up bleeding. 
Nitrate of potash still serves a variety of uses. He 
orders Dover's powder and warm wrappings to break 
up a cold, and has much faith in the liver as the source 
of all obscure ailments, and in the corrective efficacy 
of blue pill and black draught. He still treats dyspep- 
tic stomachs with quassia-chip bitters, and if this does 
no good he gives judicious suggestions as to dieting. 
Dietetics does not constitute a favorite branch of thera- 
peutics with him, yet experience has taught him many 
of the simplest and most peremptory rules. 

A large part of the country physician's duties is to 
prescribe for those that are simply " run down," debil- 
itated, suffering from " functional ailments," from cold, 
overwork, dietary indiscretions ; and in treating such 
patients, he generally brings into exercise the princi- 
ples of good judgment and common sense. Even if 
now and then a puzzling case, as of multiple peripheral 
neuritis, comes before him for diagnosis and treatment, 
though the diagnosis may be at fault, the treatment may 
not be altogether harmful. 

In the management of children's diseases, the coun- 
try physician may be somewhat badly off without the 
multitudinous preparations called " infants' foods," 
which his city confrere possesses, yet with pure cow's 
milk and flour gruel he gets along fairly well, and sees 
some cases of intense athrepsia recover under good 
hygiene on very simple nourishment, and finds indeed 
a pleasure in seeing his patients' city grandchildren 
grow healthy and strong under his care during their 
summer vacation. 

In his obstetric practice, the average country physi- 
cian, though he uses no antiseptics, has the benefit of 
pure air, and that is almost everything. He may be 
a little slow about putting on forceps, but he claims 



44 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 10, 1890. 



that time with him is not so precious as to make 
" meddlesome midwifery " justifiable, and that in 
" hundreds of cases " he has seldom found the necessity 
for " interfering with nature's processes," yet for a 
severe emergency, he is generally equipped and equal. 

The country physician deserves high consideration 
from his fellows, for his lot, if he be a successful prac- 
titioner, is a laborious and largely unselfish one ; we 
say unselfish, for no one is more a servant of his con- 
stituency than he, and does so much drudgery for so 
little pay. When his work is done for the day his 
nights are by no means undisturbed by calls; he is 
really always tired, and seldom in mood for study or 
the microscope. His city confrere, having his patients 
near home, can do in a few hours an amount of work 
that would take the country practitioner all day long, 
for his patients are often a long distance from home. 
A drive of ten miles and back over a rough road in the 
forenoon, and a similar ride in another direction in the 
afternoon, with other calls saudwiched in, and an obstet- 
ric case in the night make considerable draughts on 
the energy of even the most vigorous man ; and when 
we consider that the country doctor is generally a 
farmer as well, and think of the social demands on his 
time (he is often Superintendent of the Sunday School, 
leader of the " Class Meeting," or the " Prayer Meet- 
ing," President of the " Debating Society," or "Liter- 
ary Club," perhaps "Chairman of the School Board"), 
we wonder at his powers of endurance and the extent 
and variety of his labors, and we feel that he rather 
deserves praise that he is so useful a man rather than 
blame that he has done so little for medical science. 



THE SURGICAL FOURTH. 

The surgery of the Fourth of July is sufficient in it- 
self to justify some forethought on the part of surgeons 
in the larger places, and presents possibilities not always 
pleasant to every one engaged in general practice. 

The character of such surgery changes from year to 
year as fashion or progress in the knowledge and 
manufacture of explosives changes the character of 
the noise-producing materials. But a few years ago 
the blank cartridge lodged its wadding in the palm of 
the hand with wonderful frequency, and lockjaw was 
by no means an unfrequent sequel of such an accident 
in various parts of the country. 

The deadly toy-pistol, as it was appropriately 
named by the press, has become less potent as a de- 
structive agent because of the prejudice aroused against 
it as a dangerous plaything and the recognition of the 
necessity of caring for its wounds. It has been Sup- 
planted by the giant cracker. The pistol reaped its 
harvest among small boys of about a dozen years of 
age, more or less. The giant cracker seeks its vic- 
tims among those boys whose size and years should 
give them the attributes of men. The results of the 
cracker are the more or less complete destruction of 
the hand in which it is held. These crackers are of 
various sizes designated by numbers, and vary from 



those twice or three times the size of the ordinary 
cracker to those twenty times its size. Occasionally 
some foolhardy individual will hold one in his hand 
from a spirit of bravado, occasionally because it is 
supposed to be a Roman candle, but the majority 
of injuries are purely accidental. Either the fuse 
burns faster than was expected and the explosion 
takes place before the cracker can be dropped, or the 
cracker fails to explode for so long a time that it is 
supptsed to have gone out, and it is picked up and ex- 
plodes in the hand. 

There is one peculiar feature of these giant-cracker 
explosions in the hand. In a large proportion of cases 
the base of the thumb is split open and a compound 
dislocation produced at the joint of the first metacarpal 
and the trapezium, so that the thumb and its metacar- 
pal retain their connection with the rest of the hand 
only by the soft parts, the tip of the thumb being little 
or not at all injured. If these injuries are carefully 
cleaned of powder and dirt, they heal as readily as 
could be expected from the severity of the explosion 
and the extreme laceration of the wound; but the en- 
tire loss of the hand is not unusual. Tetanus is not a 
frequent result; no single instance of its occurrence 
after these injuries has occurred in the knowledge of 
the writer. 

The Fourth just passed seems to have been less 
prolific in injuries than those that have recently pre- 
ceded it, but it has left much to be desired. There ap- 
peared at the Boston City Hospital — the only hospital 
whose statistics are available at the moment of writing 
— twenty-one injuries from explosion, of more or less 
severity. At least seven of them will result in the 
very great diminution of the usefulness of the hand, 
though none demanded amputation of the arm. 

It would be pleasant to think that the public was 
awakening to the wanton waste of life and limb our 
method of celebrating the Fourth incurs. 

MEDICAL NOTES. 

— Press despatches under date of about July 1st, 
announced cholera to be on the increase in and about 
Valencia, and to have broken out in Portugal. Some 
alarm is felt in London and Paris. In the latter city 
the government has put to work some 22,000 men at 
filtering the water-supply. 

— The Christian Union for June 20th contains an 
article on " The Advantage of the Woman's College 
to the Women of America," by Mrs. Alice Freeman 
Palmer — who, as Miss Alice Freeman, was, until 
her marriage, the president of Wellesley College. 
Mrs. Palmer claims that one of the most important 
influences of the woman's college has been its influence 
for strong health. " In its robust pleasures and intel- 
lectual struggles it has had no place for the interest- 
ing invalids of former times. More than any one 
agency it has contributed to make blooming health 
expected of women. It has insisted upon regular and 
simple modes of life, It has founded, gymnasiums 



Voi,. CXXTII, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



45 



and encouraged athletic sports for girls. It lias had 
field and lake and river at the service of its students, 
and has employed salaried physicians and directors 
for their safety and guidance. By its varied resources 
and opportunities it has shown how rich and honora- 
ble a thing physical life is, and how well worth ruain- 
taining at its highest point of enjoyment and power. 
All the college women I have known wish to be strong. 
They rarely confess themselves weak and ailing with- 
out, an inward sense of shame. They know that lack 
of self-control — nervousness — is not a necessity 
even to this hurried and high-strung generation.'" 

NEW ENGLAND. 

— Among those who have died of typhoid fever in 
the recent epidemic in Waterbury, Conn., which is 
said to have been traced to a milk-supply, was City 
Engineer Weld, a member of the Waterbury Board 
of Health, and a practical sanitarian to whom the city 
is indebted for its system of sewers. This man had 
labored long and earnestly in defence of the public 
health so far as the removal of unfavorable conditions 
within the city limits was concerned ; but in the prime 
of life he has been cut off by poison sent to the city 
from a farm where the farmer himself lay ill of ty- 
phoid fever and from which an employee had recently 
been taken to the City Hospital, there to die of the 
same malady. 



A PHYSICIAN'S NOTES IN CENTRAL AFRICA. 

We find in the British Medical Journal for June 
1 ith, some " Gleanings from the Diary of the Physi- 
cian in Central Africa," from which we make a short 
extract relative to certain habits among the Wanyoro, 
one of the two most powerful tribes inhabiting the 
fertile lands between Lakes Victoria and Albert. 

" When a woman is pregnant and labor commences, 
all the women of experience are summoned to assist 
her. She sits on her heels, her knees stretched far 
apart, while one or two women support her back and 
arms, and the midwife sits in front of her ready to 
receive the child. Delivery is promoted by rubbing 
the uterus. If the head presents it is considered a 
good sign ; if the feet present, it announces misfortune 
to the family. Should an arm presentation occur, it 
is replaced and an attempt is made to turn ; this opera- 
tion is performed by men who receive special presents 
for the service. Should a woman die in childbirth, 
abdominal section is at once performed, and the child, 
whether living or dead, removed. Many women die 
of flooding, probably arising from attempts to remove 
the placenta. The umbilical cord is cut with a sharp 
splinter of reed, at a considerable distance from the 
navel, and is tied to the body of the child until it 
shrivels or falls off, which is hastened by frequent 
rubbings with fat. Ligature is quite unknown. The 
fifth day after birth the mother takes her child and 
sits with it on the threshold, and the name ceremonies 
take place. The child is suckled for eighteen months, 
during which time the mother lives apart from her 
husband. Many women are barren, and most of them 
have only two or three children. Unlimited polygamy 



is stated to be one of the causes which reduces the 
population. Unyoro women only bear children be- 
tween the ages of twelve and twenty-five. A son 
inherits all his father's wives, who become his wives, 
with the exception of his own mother. Theft is pun- 
ished by confiscation of property for the benefit of 
the person robbed ; murder, by the slaying of the 
murderer by the nearest relatives; and adultery, by 
the wife being beaten and a fine paid by the offender. 
Prostitutes are a privileged class, living under the 
protection of the king, and they are the servants of 
his wives. Though prostitution exists in all negro coun 
tries, it is officially sanctioned only in Unyoro. Pri- 
vate property in land does not exist. The passion 
for human flesh is hereditary in some families, but 
cannibalism is practised secretly. These wild tribes 
are not free from what are often thought to be the 
diseases of modern life. Epilepsy is common among 
them, and no cure is known for it. Insanity and also 
mental aberration are frequent ; the latter is treated 
with herbal remedies, which effect an immediate cure 
by means of sweating and sleep. Polydactylism is 
rare ; if the. superfluous fingers are noticed at birth 
they are at once removed. Small-pox is much dreaded, 
and the pustules are opened and washed with warm 
water, but the sufferers usually die. Vaccination is 
quite unknown, and syphilis is very prevalent, but 
widespread disorganization is rare, and there is a ten- 
dency to self-healing. The sores are dressed with 
caustic herbs, and are thereby made worse. Exosto- 
sis is common, and its syphilitic origin recognized. 
The same is true of partial loss of pigment, which is 
very common in Uganda. Syphilis is said to have 
been unknown formerly ; it has followed in the track 
of the Nubians." 



A CASEIN WHICH CEREBRAL LOCALIZATION 
WAS ILLUSTRATED P.Y THE EFFECT OF 
MENTAL IMPRESSION. 

Dr. Andrew H. Smith reports a case, interesting in 
the above connection, in the American Journal of ihe 
Medical Sciences for July, 1890. 

"Mr. I. consulted me about three years ago for a 
condition of the right wrist and band, from which he 
had suffered for several years, and which resembled 
writer's cramp, but differed from that affection etiolog- 
ical!}', and in that the condition was one of tremor 
rather than of spasm. It was not the result of any 
special or excessive use of the hand, and was asso- 
ciated with a slight degree of paresis of the right leg. 

"There was a good deal of occipital pain, which I 
found to be dependent upon defective action of the ocu- 
lar muscles. This was completely relieved by prisms 
selected by Dr. Noyes. Singularly, not ouly was the 
pain relieved by the use of the glasses, but the condition 
of the hand and leg was considerably improved. 

" As a great variety of treatment had been tried before 
I saw the patient, and he had suffered much of many 
physicians, specialists iucluded, I now advised him to 
rest content with the measure of relief he had obtained, 
and to desist from further treatment, diverting his mind 
as much as possible from his condition by active em- 
ployment. 

" Pursuing this course he has gotten on in the main 
very well up to the present time. His general health 
has improved, and the hand and leg are decidedly 
better. He is, however, still obliged to write with 



46 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 10, 1890. 



his left hand, although the right is fairly useful for 
other purposes. 

"This was his condition when, a few days ago, he 
hecatne interested in reading the article in Harper 's 
Magazine for May, in which Mr. Chittenden describes 
his experience in signing, as Register of the Treasury, 
12,500 United States bonds in sixty-four hours, and 
the physical distress which the effort occasioned. As 
he progressed in the reading Mr. I. experienced a 
severe pain, beginning in the right hand, running up 
the arm into the neck, then into the occiput, and at 
last settling with great intensity in a circumscribed 
spot on the left side of the head. In describing this 
pain to me he indicated with his finger as accurately as 
I could possibly have done, the exact situation of the 
postero-parietal convolution in which Ferrier locates 
the centre for the wrist and hand of the opposite side. 
Some pain was also experienced in the leg. 

" Now, this gentleman had no kuowledge whatever of 
cerebral localization beyond the broad fact that the 
brain on one side actuates the muscles on the other. 
The pain he described could not, therefore, have been 
the result of suggestion. The conclusion seems inevi- 
table that the phenomena in the hand and leg had back 
of them a morbid condition of the cortical centre, and 
that this morbid condition was in such wise influenced 
by the direction of the mind toward the function of 
that centre as to express itself in pain. Probably the 
intermediate link between the mental action and the 
production of the pain was a vaso-motor disturbance. 

" Experiments, especially those of Amidon, indicate 
that functional activity of a cortical centre may give 
rise to an appreciable increase of the local temperature. 
This observation, however, would seem to show that 
merely occupying the imagination with a function may 
excite a degree of disturbance in the centre correspond- 
ing to that function. 

From a diagnostic point of view, the attack of 
pain so strangely elicited is important as confirming a 
cortical origin of the symptoms. From the implication 
of the leg it is probable that the posterior portion of 
the convolution was also involved. 

" If we accept Ferrier's earlier conclusions as to the 
function of the angular gyrus in relation to the move- 
ments of the eyes, we find in the proximity of this gyrus 
to the postero-parietal convolution a probable explana- 
tion of the improvement in the hand and leg when the 
eye-strain was relieved. The more recent views, how- 
ever, as to the location of the centre for ocular move- 
ments, remove it so far from this region that this expla- 
nation scarcely seems tenable." 



A CASE OF ACUTE PANCREATITIS. 

The interest in this class of cases leads us to print 
the following brief report of a case condensed in the 
London Medical Recorder from the Wiener Med. 
Wockensch. : 

The patient, a man aged sixty, was suddenly taken ill 
with severe vomiting, headache, giddiness and depres- 
sion. Soon the abdomen began to swell (the next 
night). There was dyspnoea, also painfulness in the 
left bypochondrium. On reception into the Charite 
Hospital, a transverse retraction of the abdomen was 
to be noticed above the navel. Above and below this 
there was great distension. There was slight fever, 
with a weak pulse, and a few spots ; and typhoid 



fever was diagnosed. During six weeks the symp- 
toms altered but little. Towards the end the vomited 
matter smelt as if decomposed. Within a fortnight 
afterwards the patient died. The autopsy showed 
complete necrosis of the pancreas, which lay in a sac 
formed by the surrounding organs, and containing a 
thick fluid, with remains of the vessels and some loose 
fatty tissue. Various openings led into the neigh- 
boring intestine. There was extensive necrosis of 
fatty tissue. The appearances seemed most probably 
the result of a very acute inflammation of the pan- 
creas." 



J Correspondence. 

A GRAND EXHIBITION OF HYPNOTIZING. 

Boston, July 7, 1890. 

Mr. Editor: — Gentlemen who have of late been ex- 
perimenting with a few individual cases in which the phe- 
nomena due to " suggestion " are apparently well marked, 
might find a wider field for investigation in the symptoms 
due to suggestion, which characterize the grand army (sic .') 
of invalids who are applicants for pensions. 

A claim-agent fixes his penetrating glance upon some 
worthy fellow who gallantly served his country twenty-five 
years ago. Up to this time, he, the soldier, has been man- 
fully at work supporting his family, unconscious of being 
the proud possessor of any chronic ailment, although, per- 
haps, at times he may have realized that a man of fifty or 
fifty-five years was not quite as spry and active as when 
he had only the burden of half that number upon his 
shoulders. 

But the mesmeric gaze of the claim-agent brings him 
into subjection. As he comes under its influence, the sug- 
gestion is made after this fashion : " You straighten up 
slowly when I speak to you? That is due to chronic rheu- 
matism of the back, which you contracted when you were 
on picket at Mine Run, you remember that you got wet 
lying in the swamps. You have a pain in your bowels? 
Yes, of course ! The diarrhoea that followed eating the 
mince pies sent you from home at Brandy Station, and 
which, if it had continued, would have become chronic, has 
undermined your digestive system and you are a perfect 
wreck. You are not fit to work any more ; go see your 
local physician and tell him all your symptoms — -be sure 
and tell him all, or even a few more — and ask him if in 
his opinion they are not all attributable to exposure during 
your army service. Write to your regimental surgeon for 
a certificate to the fact of your getting a backache while 
on picket and the diarrhoea during winter quarters. Get 
a few more certificates from company officers and com- 
rades, then bring them all to me, and, I /rill get you a pension 
so that you need labor no more." 

Once fairly hypnotized, the good fellow comes readily 
under the influence of friends and pensioned comrades who 
make similar suggestions. Forced to follow these, the man 
seeks his local physician, who truthfully tells him that 
nothing in civil life would produce such a jumble of symp- 
toms, and consequently they must be due to his army ex- 
perience. The regimental surgeon finds in an old note- 
book memoranda of the two illnesses, and properly certifies 
to the facts. The examiner for pensions looks at the evi- 
dence, and endeavors to connect the assigned cause with 
the stated present condition, and honestly (for the man is 
now really ill by suggestion) passes him ; although it may 
not be exactly clear to him how it came about. Now 1 
maintain that in a considerable proportion of applications 
for invalid pensions (and I mean those where no fraud is 
intended), the specific hypnotization practiced by the 
claim-agent, aided by the generally prevalent impression 
in the community, that arm)- service must injure a man's 
health in some way, makes a man really ill. The man is 
honest in thinking himself affected with some disease. 

A case in point: one of the most straight-forward young 



Vol. CXXIII, No. 2.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



47 



men whom f ever knew, a first-rate non-commissioned 
officer of the medical department, plucky and honest, came 
tome in these latter years with the story of failing eye- 
sight, which all of his friends assured him must have had 
its origin at a time when his regiment was camped in a 
valley, so situated thai the thick smoke from the camp-fires 
of the corps settled down among the tents for several days, 
warranting the appellation given it of " Smoky Hollow." 
1 referred him to an eminent oculist, who plainly told him 
that his sight was good enough for a man of fifty, and that 
nothing was the matter with his eyes, save the wear and 
tear of twenty-five years' use since he left the army. In 
his honest, man-fashioned way, he at once gave up all 
thought of applying for a pension, although he well knew 
that others of his comrades had obtained such for no better 
cause than his. 

It seems proper that the medical profession should pro- 
test against this manufacture of disease by suggestion. If 
we must have hypnotism in daily life, let it be remedial, 
not causative. I am not writing against pensions, I am 
only setting forth the fact that the pension germ has been 
a powerful factor in producing disease in that portion of 
the community who served their country in the field during 
the late war. I do not keep up with the times in the study 
of germs, but I think that f am right in stating that this 



peculiar germ differs from all others in having no specific 
function, but can infect any portion of the system, causing 
any disease in any part from an ingrowing toe-nail to a 
bald head. An Oi.ij Army SuROKON. 



IODIDE OF 



SODIUM AND 
TASSIUM. 



IODIDE OF PO 



Salkm, July 3, 1890. 
Mr. Editor : — In the March-April number of Annates 
d'Oculistique is a brief article, signed " W " (presumably 
Dr. Warloment), referring to a paper, by Dr. Laborde, on 
the comparative action of the two above-named salts, which 
was read before the Paris Academy of Medicine on the 
4th of March. 

It is an unpleasant surprise to those of us who have pre- 
scribed the sodie iodide, because it is more palatable and 
also better borne, apparently, than its displaced isomer, to 
be informed on high authority that it is almost inert. As 
to the bromide of sodium, clinical experience in the use of 
this salt seems to warrant the belief that its action is nearly 
identical with that of the bromide of potassium. 

D. Coggin, M.D. 



REPORTED MORTALITY FOR THE WEEK ENDING JUNE 28, 1890. 



Cities. 



New York 

Chicago . . 
Philadelphia 

Brooklyn . . 

St. Louis . . 
Baltimore 

Boston . . . 
Cincinnati 
New Orleans 

Pittsburgh . 

Milwaukee . 

Washington . 

Nashville . . 

Charleston . 

Portland . . 
Worcester 

Lowell . . . 

Cambridge . 
Fall River 

Lynn . . 

Springfield . 
Lawrence 
New Bedford 

Holyoke . . 

Somerville . 

Brockton . . 

Salem . . . 

Chelsea . . 

Haverhill . . 

Taunton . . 

Gloucester . 

Newton . . 

Maiden . . 

Waltham . . 
Fitchburg 
Attleborough 

Pittsfield . . 

Quincy . . 
Newburyport 

Woburn . . 











Percentage of Deaths from 




Estimated 


Reported 


Deaths 






















Population 
for 1890. 


Deaths in 
each. 


under Five 
Years. 


Infectious 


Consump- 


Diphtheria 


Diarrhoeal 


Typhoid 


Diseases. 


tion. 


and Croup. 


Diseases. 


Fever. 


1,622,237 


875 


499 


32.45 


8.80 


3.63 


22.88 


.11 


1,IUU,UUU 


OOO 


10* 


22.62 


12.10 


2.86 


8.32 


7 Uf\ 


1,061,277 


526 


292 


23.56 


7.41 


.76 


19.76 


1.90 


852,467 


473 


290 


38.01 


7.77 


4.83 


29.40 


.63 


550,000 
















500,343 


252 


129 


32.76 


6.24 


.39 


28.08 


.78 


418,110 


140 


49 


16.33 


17.04 


10.65 


2.13 


.71 


325,000 


234 


127 


30.96 


4.30 


2.58 


22.36 


2 15 


260,000 


158 


61 


18.90 


11.34 




11.97 


1.26 


240,000 
















240,000 
















230,000 


143 


73 


31.50 


8.40 


1.40 


21.70 


4.90 


68,513 


41 


18 


31.72 


4.88 




26.84 




60,145 


45 


17 


13.32 


15.55 




4.44 


4.44 


42,000 


8 


3 




12.60 








81,622 


25 


11 


16.00 


8.00 


16.00 






73,370 


30 


11 


13.33 


13.33 




13.33 




67,026 


22 


8 


7.14 


11.71 




3.57 


3.57 


64,092 


28 


18 


28.56 


17.85 


3.57 


25.00 




55,200 


5 


5 . 




60.00 








41,520 
















41,058 


17 


7 


11.76 


23.52 






5.88 


38,218 


15 


1 


6.66 


26.66 






6.66 


37,867 
















35,516 
30,811 






























29,242 
28,781 


9 


3 




11.11 








9 


1 


33.33 


22.22 


11.11 


11.11 


11.11 


27,124 


4 


2 


50.00 






25.00 




25,544 


4 


1 




25.00 








24,904 


5 





40.00 










22,011 


3 


1 












20,615 


11 


5 




18.18 








17,998 


3 


1 




33.33 








17,304 


3 















15,994 
















15,762 


2 







50.00 








14,114 


6 


2 


33.33 


16.66 






16.66 


13,915 


2 







50.00 








13,089 

















Deaths reported 3,484 ; under five years of age 1,792: principal 
infectious diseases (small-pox, measles, diphtheria and croup, 
diarrhoeal diseases, whoopiug-cough, erysipelas and fevers) - , 
consumption 316, acute lung diseases 230, diarrhoeal diseases 
658, diphtheria and croup 96, typhoid fever 68, measles 39, 
whooping-cough 33, cerebro-spinal meningitis 25, malarial fever 
18, scarlet fever 14, puerperal fever 7, erysipelas 2. 

From measles, New York 27, Brooklyn 4, Baltimore 3, Chicago, 
Philadelphia, Boston, New Orleans and Lawrence 1 each. From 
whooping-cough, New York 11, Brooklyn 6, Cincinnati 5, Chicago 



and Baltimore 3 each, Philadelphia 2, Boston, Nashville and 
Charleston 1 each. From cerebro-spinal meningitis, Chicago, 
Cincinnati and Worcester 4 each, New York and Washington 
3 each, Brooklyn and Gloucester 2 each, Baltimore, Fall River 
and Chelsea 1 each. From malarial fever, New Orleans 8, 
New York 5, Brooklyn 2, Nashville, Charleston and Haverhill 
1 each. From scarlet fever, New York 6, Chicago, Philadelphia 
and Baltimore 2 each, Brooklyn and Boston 1 each. From 
puerperal fever, Chicago 4, Washington 2, Philadelphia 1. 
From erysipelas, New York and Boston 1 each. 



48 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 10, 1890- 



The meteorological record for the week ending June 28, in Boston, was as follows, according to observations furnished by 
Sergeant J. W. Smith, of the United States Signal Corps: - 



Week ending 


Barom- 
eter. 


Thermometer. 


Relative 
Humidity. 


Direction of 
Wind. 


Velocity of 
Wind. 


State of 
Weather.* 


Rainfall. 


Saturday, 


. 
B 


a 

a 


s 


a 








c 

« 




















a 
rig 




June 28, 1890. 




9 

s 


a 
6 


| 


S 




2 




2 




2 


a 




2 






. 


l« 


*J til 

a 4> 






5 


'5 


•< 








■S3 






■■f 














i i 




'5 


"5 


■ 
S 


i 


o 




© 


'3 


e 
© 




© 
© 


© 

© 




© 
© 


© 
© 




© 

o 








Q 


O 






00 




00 


fi 


00 




00 


00 




00 


00 




00 




< 


Sunday,. . .22 


29.98 


59.0 


63.0 


56.0 


81 




83 


82.0 


E. 




E. 


8 




12 


F. 




o. 






Monday, . .2.) 
Tuesday,. .24 


30.(18 


58.0 


62.0 


54.0 


69 




86 


77.0 


N.W. 




E. 


5 




10 


C. 




o. 






29.96 


71.0 


81.0 


59.0 


85 




86 


85.0 


N.W. 




S.W. 


6 




9 


O. 




0. 






Wednes. ..25 


29.75 


75.0 


86.0 


65.0 


86 




4C 


66.0 


S.W. 




W. 


12 




12 


O. 




c. 




0.13 


Thursday, .20 


29.72 


73.0 


81.0 


65.0 


53 




65 


59.0 


N.W. 




N. 


24 




10 


C. 




F. 






Friday,. ...27 


29.81 


67.0 


71.0 


62.0 


65 




67 


66.0 


N.K. 




S.W. 


10 




5 


0. 




O. 




T. 


Saturday,. 28 


29.79 


67.0 


75.0 


60.0 


55 




81 


68.0 


N.W. 




E. 


12 




12 


C. 




C. 






Mean for 
Week. 





























» 0., cloudy ; C, clear ; F., fair ; G., fog ; H., hazy ; S., smoky ; R., rain ; T., threatening ; N., snow, t Indicates trace of rainfall. 



OFFICIAL LIST OF CHANGES IN THE STATIONS AND 
DUTIES OF OFFICERS SERVING IN THE MEDICAL DE- 
PARTMENT, U. S. ARMY, FROM JUNE 28, 1890, TO JULY 
4, 1890. 

By direction of the Acting Secretary of War, leave of ab- 
sence for four months is granted Major James P. Kimball, sur- 
geon, to take effect when an officer of the Medical Department 
is assigned by his department commander to relieve him. Par. 
0, S. O. 152, A. G. O , July 1, 1890, Washington, D. C. 

First Lieutenant Robert R. Ball, assistant surgeon, is re- 
lieved from duty at Fort Riley, Kansas, and will report in per- 
son to the commanding officer, Fort Spokane, Washington, for 
duty. S. O. 151, Par. 7, A. G. O., June 28, 1890, Washington, 
D. C. 

Captain William H. Corbusier, assistant surgeon, is re- 
lieved from duty at Fort Lewis, Colorado, and will report in per- 
son to the commanding officer, Fort Wayne, Michigan, for duty. 
S O. 151, Par. 7, A. G. O., June 28, 1890, Washington, D. C. 

By direction of the Secretary of War, the following named 
assistant surgeons (recently appointed) will report in person for 
duty to the commanding officer of the posts designated opposite 
their respective names: 

First Lieutenant Frank R. Keefer, Fort Leavenworth, 
Kansas. 

First Lieutenant Thomas U. Raymond, Fort Sherman, Idaho. 
First Lieutenant Henry D. Snyder, Fort Reno, Indian 
Territory. 

First Lieutenant Allen M. Smith, Fort Snelliug, Minnesota. 

First Lieutenant Ashton B. Heyl, Port Niobrara, Nebraska. 

First Lieutenant Joseph P Clarke, Fort Riley, Kansas. 

Par. 6, S. O. 151, A. G. O., June 28, 1890, Washington, D. C. 

By direction of the Secretary of War, leave of absence for 
two months, to take effect August 0, 1890, is granted First Lieu- 
tenant William N. Suter, assistant surgeon. Par. 3, S. O., 
June 26, 1890. 



OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS 
OF THE U. S. NAVY FOR THE WEEK ENDING JULY 
5, 1890. 

Page, J. E., assistant surgeon. Ordered to hospital, Mare 
Island, Cal. 

Kennedy, R. M., assistant surgeon. Ordered to the League 
Island Navy Yard, Pa. 



OBITUARY. HON. WILLIAM D. PECK, M.D., M.M.S.S. 

Dr. William D. Peck, who died at Sterling, Mass., June 29th, 
had been director of the Boston, Clinton & Fitchburg railroad, 
and president of the Framingham & Lowell, director of the 
State Mutual Life Insurance Company of Worcester, director of 
the Fitchburg National Bank, and president of the Fitchburg 
Savings Bank. In Sterling for forty-four years he was honored 
with a continued reelection to the town clerkship, and for thirty- 
two years he was town treasurer and collector. Dr. Peck's 
service in the Legislature included three terms in the House and 
two in the Senate, his legislative career beginning in 1818, and 
ending in 18511. Among hisclassmates in the noted class of 1883, 
Harvard College, were Professor Francis Bowen, Professor 
Joseph Lovering, Professor Henry W. Torrey, and Professor 
Jeffries Wyinan, who all became teachers at their college, and 
Rev. Dr. George E. Ellis, and Dr. Morrill VVyman. Dr. Peck 
was born in Cambridge, November 10, 1812, his father being 



William Dandridge Peck, the first professor of natural history 
at Harvard (1805-1822), and his mother being a member of the 
Hilliard family. The son was much interested in the study of 
natural history and geology throughout his life. His degree of 
M.D., was obtained at the Harvard Medical School iu 1836, the 
only surviving members of that class being Oliver Wendell 
Holmes, Alfred Day, and William Iugalls. His widow and two 
daughters survive him. 



OBITUARY. CHARLES LIN^US ALLEN, M.D. 

Dr. Charles Linaeus Allen, died July 2d, at Rutland, Vt., of 
apoplexy. He was born at Brattleboro', June 21, 1820, was 
graduated from Middlebury College in 1842, and from Castle- 
ton Medical College in 184fj. He was president of the latter 
college for several years, and was afterward Professor of 
Civil and Military Hygiene iu the University of Vermont 
at Burlington. Except during Cleveland's administration, 
he had been since the War, a member of the Board of Local 
Pension Examiners. He was Secretary of the State Board of 
Health, and had been connected with the Board since its organi- 
zation. He was the first president of the Rutland Medical 
Club, and a member of the Vermont State Medical Society, the 
American Medical Association, the American Academy of Medi- 
cine, and other societies. 



ERRATUM. 

In the Journal of June 2tith, on page 642, right-hand column, 
seventh line from bottom, "Dr. Adams, Pittsfield," should read 
" Dr. Z. B. Adams, Framingham." 



BOOKS AND PAMPHLETS RECEIVED. 

Climatology and Diseases of Southern California. By F. D. 
Bullard, A.M., M.D. Reprint. 1890. 

Woman's Medical College of the New York Infirmary. 
Twenty-Second Annual Catalogue and Announcement. June, 
1890. 

A Last Word about Christian Science, Mind-Cure and Allied 
Methods of Treatment. By Selwyn A. Russell, M.D. Albany, 
1890. 

Les Conditions Mate"rielles d'une Bonne Salle d'Ope'rations. 
Par le Dr. Just Lueas-Championniere, Chirurgien de l'hopital 
Saint-Louis. Paris, 1890. 

Another Hitherto Undescribed Disease of the Ovaries. Ano- 
malous Menstrual Bodies. By Mary A. Dixon Jones, M D., 
Brooklyn. Reprint. 1890. 

Catalogue of the Albany Medical College, Medical Depart- 
ment of Union University. Fifty-Ninth Session, 1889-90. An- 
nouncement for Session, 1890-91. 

Formulaire Aide-Mcmoire de la Faculte' de Medeeiue et des 
Me'decins des Hdpitaux de Paris. Parle Dr. Fernand Roux. 
Paris: G. Steiuheil, Editeur. 1890. 

New Methods of Performing Pylorectomy, With Remarks 
Upon Intestinal Anastomotic Operations. By A. V. L. Brokavt , 
M.D., St. Louis, Mo. Reprint. 1890. 

Outlines of Practical Histology, A Manual for Students. 
By William Stirling, M.D. Sc.D , Blackenbury Professor of 
Physiology and Histology in the Owens College, Manchester, 
etc. With 344 illustrations. Philadelphia: P. Blakistou, Sou &. 
Co. 1890. 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



49 



llccture. 



INFLUENZA IN MASSACHUSETTS. 1 

BY QHOI6I B. SHATTUCK, M.U., OF BOSTON. 

THE registration of vital statistics has uow been 
carried on long enough in this Commonwealth, is now 
sufficiently accurate and is compiled with sucli care as 
to make it of great service in any relative study of the 
past and present of diseases here. The statistics 
accumulated by the immense extension of life insur- 
ance, and the meteorological records of the United 
States Weather Bureau are other advantages of which 
the student can make use to-day. So that, notwith- 
standing the decreasing homogeneity and the increas- 
ing density of population, notwithstanding the com- 
plexity of pursuits and the exaggerated wear and tear 
of life, the task of one who seeks to investigate the 
climate of the Commonwealth and the diseases of its 
inhabitants is certainly simplified in some important 
particulars — at least over the time, not so long dis- 
tant, when the inquirer's main resource was a slow 
and precarious correspondence by letter with brother 
practitioners. 

INFLUENZA. 

Some such thoughts undoubtedly occurred to many 
when the recent pandemic of influenza swept over the 
world. It seemed positively churlish to deny hope 
the impulse to spring once more eternal in the medi- 
cal breast. With the aid of the telegraph and the 
submarine cable ; of rapid transit by sea and land ; 
of numerous weekly medical publications as well as 
of the daily press ; of the facilities for collective inves- 
tigation afforded by the frequent meeting of medical 
societies in Europe and the United States, by the 
machinery of central bureaus and local boards of 
health with mortality rates and registration of returns ; 
and above all with the aid of the entirely modern 
bacteriologist armed with his immersion lens, his cul- 
ture tubes and his staining preparations — was it not 
legitimate to hope that, if with the cooperation of all 
these more or less modern appliances we searched out 
the secrets of Nature faithfully, we should be able to 
penetrate a little farther behind her mysteries in this 
particular disease ? Was it not legitimate to trust 
that we should be able to bequeath to the future some- 
thing more than we have received from the past, 
should at least definitely determine some of the doubt- 
ful points which presented themselves after the pre- 
ceding pandemics to puzzle or ensnare the Sydenham 
Society, and Sir Thomas Watson and Hirsch and 
other sources of previous wisdom ? In short that we 
should be able to say to our successors something 
more than that an "influence" coming from we knew 
not whence, disappearing we knew not whither, and 
making a large proportion of mankind ill we knew 
uot why, had afflicted the world at a certain date ? 
It is now more than six months since the influenza 
made its appearance as an epidemic in Western 
Europe, and more than four months since it ceased to 
be epidemic in this Commonwealth. 

In Berlin, in Munich, and in Paris, Committees of 
Medical Societies, aided by government, and in Lon- 
don the Local Government Board have been at work 
upon Collective Investigations of the epidemic ; the 

1 Delivered before the Massachusetts Medical Society June 10, 
1890. Continued from page 29 of the Journal. 



Munich Committee's returns were to be in March loth, 
and the Berlin Committee's returns March 21st. The 
results have not yet reached us, though their probable 
tenor in each country may be guessed at from the 
reports of Society meetings, and communications to 
medical journals, all of which I have reviewed. I 
have been struck with the reappearance of the same 
questions arising to perplex observers in turn in all 
affected regions ; with the inevitable tendency to 
make the disease fit the limited observation of the 
individual ; with repeated proofs of the strength of 
the temptation to construct a theory upon what 
passes before one pair of eyes. I even think papers 
in Medical Journals will show that men who inclined 
to the explanation of contagion found a larger per- 
centage of enlarged spleens than men who held to the 
miasmatic theory. 

The time which has elapsed is not sufficient for the 
record and comparison of observations and experiences 
in different parts of the world ; the distance from the 
preoccupations caused by the rapid succession of 
crowded days is not sufficient to afford the necessary 
perspective for so extended a field. 

I shall ask your attention then, during the time 
which remains, to a brief consideration of some points 
in regard to influenza as exhibited in the last epidemic 
in Massachusetts. My own interest in the subject is 
derived from the experience of a large hospital ser- 
vice, of private practice, of personal illness in Boston, 
and of a general experience in Paris — all within the 
space of six weeks, from the middle of December, 
1889, to February 1, 1890, and of a pretty careful 
review of the old and recent literature of the subject 
since the cessation of the epidemic. 

So quickly do events succeed each other in our age 
and so rapidly are the scenes of life shifted, I do uot 
doubt that to some of you the subject seems already 
old and threadbare. I fear I cannot offer a sure key 
to any of its mysteries, and I may not tell you any- 
thing new, and I may weary you ; but I shall, at 
least, protect myself from a repetition of the comment 
of an esteemed colleague who, when asked lately 
about a certain address before a medical meeting, ex- 
claimed : '• Oh ! you know what it was like, some quo- 
tations from Scripture, and not a word about med- 
icine ! " 

ORIGIN. 

Where did the influenza have its origin, where did it 
come from ? Europe first heard of it in Russia, where 
it was reported as epidemic about the middle of last 
October — hence it has frequently been spoken of since 
as the Russian Influenza ; — a designation given for the 
same reason in several previous epidemics. At the 
same time that influenza exhibited itself in epidemic 
form at St. Petersburg (60° N. Lat., 30° E. Long.), 
the middle of October, it was also active at Tomsk, 
1,800 miles to the eastward in Siberia (56° N. Lat., 
85° E. Long.). A severe epidemic is reported 4 to 
have run its course in Bokhara, a district of Chinese 
Tartary (40° N. Lat., 85° E. Long.), between the 
end of May and August, 1889. This is really about 
all the information which we have on the subject of 
origin up to date. For affording trustworthy epidemi- 
ological data the heart of Asia is about what it was 
in the Middle Ages or at the time of the Garden of 
Eden, and, although further time for corrected returns 

* Prof. Drasche: Wieu. Med. Wochen., No. 6, February 8, 1890, p. 
219. 



50 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 17, 1890. 



from these outlying districts may possibly produce 
something less vague, the probability is that our suc- 
cessors will learn from us as to the origin of this epi- 
demic what we have learned from our predecessors as 
to some others — " that it came from the East." 

Present information indicates that the epidemic 
began in Berlin, the middle of November ; in Ham- 
burg, about the first of December ; in Leipzig, about 
December 10th; in Cologne, December 1st; in Paris, 
November 26th. (November 26th was the date of 
the outbreak at the great Louvre Stores.) In South- 
ern Germany, in Austria, in Turkey it was later. 
In Wurzburg and Munich it began about the middle 
of December; in Vienna, December 12th; Pesth, 
December 15th; Belgrade, December 16th; Bucha- 
rest and Sophia, December 24th. To the north of 
Paris, it began at Brussels, December 12th, and Ant- 
werp, December 16th. At London it began the end 
of December; Madrid, December 14th; Malaga, 
December 12th ; Lisbon, December 21st ; Alexandria, 
December 25th ; Cape Town, first week in January. 

INFLUENZA IN MASSACHUSETTS. 

Our State Board of Health has again justified the 
position which it has made for itself, by sending out 
promptly in January circulars to physicians, public 
institutions, and factories and employers throughout 
the State, thus providing for a collective investigation 
of this epidemic within the borders of Massachusetts. 
The board has very courteously allowed me to look 
over and collate the replies which have been received, 
and I am therefore enabled to give you more extended 
results than would otherwise have been possible, in 
anticipation of the Board's Annual Report. 

The Secretary, Dr. Abbott, will work over these 
same returns for the Board's report ; but it is not 
amiss that returns as complicated and as difficult of 
interpretation as these are should be handled indepen- 
dently by more than one individual, that possible 
errors or prejudices may be modified, on one side or 
on the other. 

The following is a copy of the circular. Those 
sent to physicians and public institutions were the 
same ; those sent to factories and employers varied as 
indicated in questions numbered 1, 3, 4, 5 and 6. 
The question in regard to sex is somewhat ambiguous. 

Commonwealth of Massachusetts. 

Office of State Board of Health. 
13 Beacon St., Boston, January, 1890. 
Dear Sir : In view of the general epidemic of influenza 
now prevailing, the State Board of Health desires to ob- 
tain such information as is possible regarding its appear- 
ance in Massachusetts during the present season, and, 
therefore, respectfully requests a reply to the following 
questions : 

(1) What was the date of first appearance of the epi- 
demic in your neighborhood ? (or institution?) (or among 
your operatives ?) 

(2) In what week was it most prevalent? 

(3) What estimated proportion or percentage of the 
population in your community was attacked ? (or of per- 
sons employed by you ?) 

(4) What ages or periods of life were most affected ? 

(5) Which sex was affected most severely ? 

(G) What was the average duration of the attack (or 
length of absence from work?) in days? 6 

(7) What symptoms predominated in the cases under 
your observation ? 

» In the Mercantile Circular, Nos. 4, 7 and 8 were omitted. 



(8) What other diseases were increased in frequency or 
severity simultaneously with the epidemic of influenza? 

manufacturer's circular. 

(4) What proportion or percentage were obliged to 
leave their work in consequence of such illness ? 

(5) What was the average duration of the attack? 

(6) Which sex was affected most severely? 

Respectfully yours, 

Samuel W. Abbott, Secretary. 

From physicians, 192 replies were received ; from 
public institutions, 24; from factories and employers, 
178 replies were received. 

PUBLIC INSTITUTIONS SUFFOLK COUNTY. 

The returns from nine of the principal hospitals of 
Boston, including the Marine Hospital at Chelsea, 
and the Boston Lunatic Hospital at South Boston, 
cover about 2,000 people, and indicate that the epi- 
demic began in these institutions about December 
21st, and was most active during the week from 
December 28th to January 4th. The City Hospital 
reports the earliest first case occurring December 16th, 
the New England Hospital the latest first case occur- 
ring December 23. The McLean Asylum, Somerville, 
reports the smallest percentage of inmates affected, 
namely: 10%. With 336 inmates there were 34 
cases, of whom 16 were male and 18 were female ; 
only two patients were attacked, the other 32 cases 
being among the attendants or employees. The New 
England Hospital for Women reports the largest per- 
centage (75%) of inmates affected. At the Children's 
Hospital 75% of officers and employees were attacked, 
and only 33% of the patients; adults reported as 
somewhat more susceptible than children. At the 
Adams Nervine Asylum 45% of the inmates — 30 out 
of 65 — were attacked; at the City Hospital 25% of 
the patients and 25% of officers and employees. At 
the Massachusetts Hospital, Dr. Pratt writes : " it 
seemed at one time that every one resident in the 
hospital had symptoms of the disease," and nurses 
and attendants were especially victims. At the State 
Prison, Charlestown, 40% of the inmates were at- 
tacked, the first December 21st ; and Dr. Sawin writes, 
" there was not a single case of pneumonia at the 
prison, although I saw many cases in private prac- 
tice " ; on the other hand, 8% of those affected had 
diarrhoea, and bronchitis was as usual frequent. 

Conclusions. — As to dates these returns agree 
pretty well with those of the mercantile companies, 
and those of the doctors, with the natural difference 
that these first cases are reported, as a rule, a few 
days later. Of seven reporting the percentage of 
patients attacked, the average is 41%. I do not feel 
justified in drawing any positive conclusion as to sex. 
There is nothing which appears positively to indicate 
exposure to the atmosphere or contagion as a factor, 
unless in the case of the McLean Asylum, where only 
two patients were attacked, and of the Massachusetts 
Hospital where the attendants suffered more, one 
infers that the attendants were more out of doon. 
At the City Hospital, on the other hand, the percent- 
age of the two classes was equal ; and in regard to the 
Children's Hospital, where 75% of officers and em- 
ployees suffered but only 33% of patients, it is to be 
remembered that children were in general less suscep- 
tible to influenza. 

Of these institutions, the City and Massachusetts 



Vol. CXXIII, No. 3.] BOSTON MEDIO AL AND SURGIOAL JOURNAL. 



51 



Hospitals are the only ones reporting pneumonia as a 
complication of or sequel to influenza. 

PUBLIC INSTITUTIONS OUTSIDE OK SUFFOLK 

COUNTY. 

Outside of Suffolk County, 12 public institutions 
reported, of which five are Insane Hospitals, one (at 
Tewksbury) an almshouse, and the others are schools 
or reformatories. Danvers is the most easterly and 
Northampton the most westerly point represented, 
and, strangely enough, each reports its first case as 
occurring on the same day, December 25th, and, con- 
trary to what might be expected, the epidemic reached 
its height at Danvers Lunatic Hospital as late as the 
third week of January, whereas at the similar North- 
ampton! institution it culminated the second week 
of January ; at Danvers 30% were attacked, but at 
Northampton only 10%. 

The Tewksbury Almshouse (North Middlesex) 
with its constant receipt of inmates from Boston, 
reports the earliest first case, December 18th, only 
two days later than the first case of the Boston City 
Hospital ; the Primary School at Monson (East Hamp- 
den) and the Lyman School for boys at Westboro' 
(West Worcester) come next with December 19th, 
although the Homoeopathic Insane Hospital at West- 
boro' and the Massachusetts Reformatory at Monson 
do not report their first cases until December 22d and 
December 26th respectively. 

The latest first cases occurred at the Lancaster 
State Industrial School (Worcester) and the Worces- 
ter Insane Hospital, at each January 3d, but the most 
active week at the former was the third week of Jan- 
uary, and at the latter the second week. The Taun- 
ton Insane Hospital (Bristol), reports its first case 
December 30th ; the State Farm, Bridgewater (Ply- 
mouth), December 31st; but the culminating week at 
the former was the third week of January, and at the 
latter the second week. 

The epidemic reached its height a week earlier at 
the Primary School at Monson than at the Lyman 
School, Westboro', last week of December and first 
week of January respectively, although it first ap- 
peared at both on the same day. The largest per- 
centage attacked was at the Primary School, Monson 
(56%) ; the smallest percentage (5%) at the Worces- 
ter, and the next smallest (10%) at the Northampton 
Insane Hospital. The Lyman School for boys reports 
50% ; the Lancaster Industrial School 42% ; the 
Reformatory Prison for Women, Sherborne, 40% ; 
the Tewksbury Almshouse 40% of its officers, and 
33% of its inmates. 

The Danvers Hospital, with 30% of inmates at- 
tacked, reports an intercurrent epidemic of measles 
with nine cases, and one of erysipelas with six cases ; 
there were a few committals in which the exciting 
cause seemed to be influenza; the senile were less 
frequently affected by influenza and females more than 
males. At the Westboro' Hospital " more females 
were attacked, but the worst cases were males " ; 
at the Worcester Insane Hospital more males were 
attacked. The Woman's Prison, Sherborne, is the 
only institution specifying insomnia as a complication. 
Only four of this group report pneumonia as a com- 
plication or sequel. 

Conclusions: — In the reports of these twelve insti- 
tutions it certainly does not appear that geographical 
position was an important factor as influencing the 



date of the first case or the maximum week. How 
far contagion could have had an influence we have no 
data to decide ; all these institutions are on more or 
less frequented lines of travel and all receive inmates 
from the outside world. 

The letter B accompanying the report of the Lyman 
School for Boys, Westboro', taken alone, suggests 
contagion. No very definite conclusions can be drawn 
as to the matter of sex. 

The average per cent, of the affected at eleven 
institutions reporting was 32%, compared with an 
average of 41% in Suffolk County. 

MERCANTILE AND MEDICAL RETURNS. 

Returns were received from 178 manufacturers and 
mercantile houses, representing all the counties of 
the State except Dukes and Nantucket. Of these I 
have tabulated 142, leaving out those which for one 
reason or another seemed too vague or unreliable. It 
cannot be said that all those, by any means, which 
have been included are entirely trustworthy, some 
are evidently more careful than others, but on the 
whole, perhaps, the errors to some degree tend to 
correct each other. I have endeavored to compare 
these returns from manufacturers with each other and 
with those from the doctors throughout the State, of 
which 192 were received and of which I have tabu- 
lated 179. I fear the success as to results is not pro- 
portionate to the amount of labor involved, but such 
as it is I will ask your attention to it. 

Beginning with south-eastern and eastern counties, 
I will pass to the western counties in order. 

NANTUCKET COUNTY. 

This Island County, standing with its neighbor 
Dukes alone as outposts in the Atlantic, sends only 
medical returns, for the good reason that manufactures 
do not exist. There are five medical returns from 
the town of Nantucket and vicinity. One places the 
first case December 20th, and the maximum week the 
first week of January ; the other four range the first 
case between December 30th and January 4th, three 
make the third week of January the maximum week 
and one the second week. 

Three think males were more affected, and two 
females. One reports pneumonia as increased, and 
two pulmonary diseases. The only return as to pro- 
portion of population affected, states 25%. 

DUKES COUNTY. 

From this Island County also there are only medi- 
cal returns ; here, as at Nantucket, the population 
lives mainly by the sea. 

There are five returns. The earliest first case is 
reported from Vineyard Haven on the north shore 
December 25th, but this was one of several exotic 
cases brought in by the Revenue Cutter Gallatin, 
and another return from the same place dates the 
first native case January 2d ; the other three returns 
from Edgartown, Cottage City, and West Tisbury 
date the first case January 1st; three returns giving 
a maximum week, name first, second and third weeks 

6 "The first case was a teacher in one of the Schools who had 
charge of thirty boys. About December 14th she spent a day in Bos- 
ton, and was taken ill December 19th, recovering in four days. In 
about five days the boys in her school began to be sick, and 28 had 
the disease in some degree within two weeks. I should say all were 
taken sick with in one week and before the disease appeared in any 
other school. The disease then invaded the nearest school, and in a 
few days had reached all of the six which make up the institution. 
Out of 190 boys, 132 had the influenza." 



52 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 17, 1890. 



of January ; these same returns give 20%, 33% and 
66% as the proportions of population affected. Av- 
erage 40%. Two returns state that males were more 
affected, and one that females, " because males had 
greater power to throw off the disease quickly." One 
return gives pneumonia and one pulmonary diseases 
as increased. 

Conclusions. — The return from these island coun- 
ties indicate that influenza invaded them two weeks 
later than the mainland further east. In the winter 
months they have comparatively little communication 
with the mainland ; the population is thus less exposed 
to contagion, though freely open to atmospheric effects, 
especially those coming from the eastward across the 
Atlantic. 

Before drawing the obvious conclusions in favor of 
contagion and against atmospheric miasm I ask your 
attention to two interesting letters. 

Dr. Banks, Surgeon Marine-Hospital Service, writes 
from Vineyard Haven, January 25th : " December 
25th I treated seven cases, seamen landed from the 
Revenue Cutter Gallatin which put in here in conse- 
quence of this trouble with her crew. 7 This is 
the first record I have of the appearance of the 
epidemic here, and shortly after I was seized with an 
illness of a like character. . . . 

" In this connection as showing an undoubted at- 
mospheric influence in the propagation of the dis- 
ease, read a report similar to mine comprising seven- 
teen cases on the Revenue Cutters 8 Woodbury and 
Dallas at Portland, Me., which occurred on board these 
vessels while at sea attending to their duties in cruis- 
ing along the coast." 

Dr. Luce writes from West Tisbury, January 31st: 
— "I first observed the epidemic during the spring of 
1889, when it appeared in its greatest severity during 
the months of March and April. It was not then 
epidemic in the State, so far as I know. I should 
think that at this time about one-third of the inhabi- 
tants were affected. ... It was most frequent among 
males, especially among fishermen and those exposed 
to inclement weather. The symptoms in this epi- 
demic were principally referable to the respiratory 
organs. 

"The present epidemic began about the first of 
January and is still upon us, affecting fully two-thirds 
of the population. In some instances the schools 
have been closed, so many of the pupils were af- 
fected. It affects all ages, but is principally confined 
to males. 

" The symptoms are more variable than in previous 
epidemics. I think I recognize three different forms 
of the disease: (1) bronchial or catarrhal; (2) febrile, 
with a second rise in temperature after the drop in 
several cases ; (3) neuralgic. 

" I have seen only one case of supervening pneu- 
monia, and that was in the spring epidemic. I have 
seen in connection with the present epidemic four 
cases of herpes zoster, more than I have seen here 
before in many years. Influenza seems to be a com- 
mon disease here." 

Dr. Lane writes also from Vineyard Haven : " There 
was no evidence of its being communicated by or 
from one person to another, even when occupying the 
same room or bed through severe cases lasting two 
weeks." 

' Abstract of Sanitary KcportH, January 6ii. 
' Ibid. January 17th. 



BARNSTABLE COUNTY. 

This county furnishes only one manufacturer's re- 
turn, and that from a shoe shop at Orleans on the 
arm of Cape Cod. The first case occurred January 
14th, the greatest prevalence was during the fourth 
week of January, 33% of sixty -six employees were at- 
tacked and absent from work on an average of four 
days. The return of the doctor at Orleans, on the 
other hand, reports the first case as occurring in his 
neighborhood on December 27th, the greatest preva- 
lence during the first week of January, 33% of the 
population as affected, males the most severely af- 
fected, and pneumonia as increased. 

Medical Returns. — From physicians in Barnstable 
County there are fifteen medical returns from eleven 
towns, all the way between Truro on the northeast arm 
of the Cape to Sandwich at the southwest border. At 
Truro the first case is dated January 1st, and the great- 
est prevalence the last week of January ; from Well- 
fleet, ten miles away, the first case is reported No- 
vember 20th, and the prevalence the third week of 
January; Chatham, December 22d and the second 
week of January ; Harwich, January 1st and second 
week of January ; Brewster about the same ; West 
Dennis, December 20th and second week of January ; 
but South Dennis, December 1st and first week of 
December. Of two reports from Hyannis, one places 
the first case December 10th, the other December 
25th. Of four returns from Sandwich, one places the 
first case October 6th, two December 20th and one 
December 27th; one gives the first week of January 
as that of greatest prevalence, two the second week 
and one the third week ; one reports 50% of the 
population of Sandwich as mildly affected and 12% 
severely, another 30%, and another 25%. 

Conclusions. — The greatest percentage of affected 
(75%) is reported from Harwich, West Dennis and 
Osterville; the least percentage (10%) from South 
Dennis ; of the two reports from Hyannis one gives 
10% as affected, and the other 25%. The average of 
thirteen towns is 37%. 

Sex. — The only point which can be fairly well es- 
tablished from the Barnstable medical returns is, that 
males were more severely affected than females, and 
probably — as one doctor puts it — " because they 
were more exposed to the weather." Ten out of fif- 
teen report " males," two females, one is doubtful, 
one says no difference. From Sandwich one return 
says "males," one says "females," one "rather more 
females," and one says " no difference." So that, on 
this point, Sandwich remains in doubt. 

Other Diseases. — Six returns from this county re- 
port pneumonia as increased, and four pulmonary 
diseases. 

( To be continued.) 



— The House Committee on Invalid Pensions has 
agreed to report favorably a bill which provides that 
all women employed by the Surgical Department of 
the United States as army nurses or otherwise offi- 
cially recognized as such during the late war, and who 
served in hospitals, in camp or on the battlefield for 
six months or more, and who were honorably dis- 
charged, and who, from the results of such service or 
the infirmities of advancing age, are unable to earn 
their own livelihood, shall receive a pension of $12 
per month. 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



53 



Original %xtit\t&. 



CASES ILLUSTRATIVE OF SOME OF THE 
MORE UNUSUAL FORMS OF BLADDER DIS- 
EASE AMONG WOMEN. 1 

BY OHJJEbUSS P. STKONO. M.D., 

Physician to Out- Patients, Massachusetts General Hospital ; Assis- 
tant Surgeon, Free Hospital for Women; Assistant In (lynxcolnyy , 
Harvard Medical School. 

The cases to which I invite your attention by the 
clinical notes I shall give this evening I have selected 
as representing either by the unusual severity of their 
symptoms or the obscurity of their lesions, some of 
the less common types of vesical disturbances. We 
are familiar with the more common forms which 
occur as accompaniments of g3'necological conditions, 
either as reflex or mechanical processes ; of those 
which disappear with but little if any local treatment, 
I shall not speak. The tendency is to assume that, 
given any pathological condition of the reproductive 
organs, bladder symptoms must by this be accounted 
for. Hence too often, exploration and careful diag- 
nosis are neglected or postponed, and a disease which 
might be mild in its beginning becomes an intractable, 
chronic affair. Nothing is simpler than an examina- 
tion from the meatus to the exploration of the whole 
interior of the female bladder. The endoscope with 
electric light is valuable but not necessary. The 
small endoscope I show here is sufficient, with the 
aid of an ordinary head-mirror and lamp. Since the 
introduction of cocaine, ether is not necessary, but is 
always preferable. Simon's plugs are the most desir- 
able form of dilators and furnish, too, an efficient 
instrument of aid in medication. 

The first cases I shall consider are those of hsernor- 
rhage from the bladder, not from malignant growths 
but from the villous formation resulting from chronic 
cystitis. These are not the usual forms in which the 
disease manifests itself. I have met with four cases 
in which a diagnosis of malignant disease of the 
bladder had been made, but which were cured without 
return, by the treatment employed. 

The most pronounced cases were the following : 

Mrs. Mcl., thirty-eight; married; no children. Haem- 
orrhage from the villi of chronic hyperplasia of vesical 
mucous membrane. Referred to me in 1881 for pallia- 
tive treatment of malignant disease of the bladder. In 
four years there had been steadily increasing pain 
about the bladder, with but little pain in micturition. 
The urine at times appeared slightly bloody. During 
the past year there had been decided deposits of a 
blood-stained sediment, and in the past eight months 
decided haemorrhages had occurred, with the passage 
of large clots. During the past two months haemor- 
rhage had been so excessive as frequently to induce 
syncope. The patient was blanched, and certainly 
looked as if she had the cachexia of malignant disease. 
Micturition was frequent, but not extremely painful. 
The passage of a sound started up such decided haem- 
orrhage that it was necessary to dilate rapidly the 
urethra, which was free from disease. The finger 
entering the bladder met everywhere soft villous 
formations, many of which were capped by a phos- 
phatic deposit. These outgrowths were especially 
massed in the vicinity of the ureters. The sharp 
curette was used to remove these, leaving a clean 
base everywhere, and immediately stopping the haem- 
1 Bead before the Obstetrical Society of Boston, April !'_>, 1890. 



orrhage. The bladder was drained and irrigated 
several times daily with boracic-acid solution. The 
convalescence was uninterrupted, and the patient still 
continues well. 

The treatment employed here is that with which I 
have obtained the best results in this class of cases ; 
and in chronic cystitis it may well be employed. The 
curette is quite as useful in hyperplasia inside the 
bladder as within the uterus, and if employed early 
would in not a few cases do awaj' with the necessity 
of establishing permanent fistuhe for drainage. 

The cases in which frequent micturition is contin- 
ued by a contracted bladder after cure of the original 
vesical disease form a series of which I wish to speak. 
Normally containing with ease a much larger quantity 
of urine than the male bladder, in consequence of 
lesions which especially involved the urethra, the 
bladder, by its reflex activity, is coutinually con- 
tracting, acquiring thickening of its muscular walls 
and assuming the shape of a firm, round ball with a 
very small cavity. There is but one treatment for 
this, — steady and progressive dilatation by frequent 
hyperdistention with aseptic solutions. Systematically 
pursued, this will certainly effect a cure, although 
much time may be required. An illustrative case is 
the following : 

Miss T., single, twenty-two, consulted me October 
26, 1883. For five years she had suffered from too 
frequent micturition. The exciting cause, she thinks, 
was hyperdistention from voluutary retention. From 
a comparatively insignificant beginning her condition 
had steadily grown worse, and at this time she passed 
her water every twenty minutes or oftener, day and 
night. For two years past she had received constant 
local treatment, but had never been examined. She 
was, of course, debarred from every enjoyment, and 
reduced nearly to a condition of insanity from the loss 
of sleep and the suffering accompanying each act of 
micturition. The largest quantity of urine she had 
voided at one time for many months was less than 
four drachms, and this was in consequence of the rest 
obtained by opiates. 

There was an anteflexion of the uterus, but without 
ether it was impossible to make a vesical examination, 
and as the patient refused this, for a month, I made a 
thorough trial of diluents and internal medication, 
and such sedatives as were not opiates. Her condi- 
tion steadily grew worse. I had her keep a record of 
the number of times she attempted to pass water dur- 
ing twenty-four hours ; the intervals averaged ten 
minutes. 

Early in December, under ether, I made a thorough 
examination with the endoscope. The bladder wall 
was clear and free from inflammation, as I had been 
led to expect by the character of the urine. The 
urethra was the seat of intense chronic inflammation. 
I applied over the whole surface a strong solution of 
nitrate of silver. For the next few days the bladder was 
in a state of constant tenesmus, requiring full opiates to 
control it; but as soon as the acute reaction from the 
treatment passed away, almost imperceptibly the in- 
tervals between the acts lengthened. 

January loth. She retained her urine one hour. 

February 15th. For several days has retained urine 
two hours during the day and two and one-half at 
night. 

Early in March she had an attack of catarrhal gas- 
tritis which greatly reduced her, and there was a re- 



54 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 17, 1890. 



lapse to intervals of thirty minutes to one hour. Just 
previously to this attack she had gone three hours, 
twice, the longest period for years ; but the quantity 
she passed at this time was not much increased. Up 
to this time I had been satisfied to refrain from any 
interference with the urethra except by weekly or bi- 
weekly injection of a very weak solution of nitrate of 
silver. Examining again, I found there were several 
patches of urethritis that were not healed, and upon 
these the strong solution was applied ; and again the 
interval lengthened to two hours. 

There was one feature now prominent in the case 
that puzzled me. On one day she would pass her 
water every two hours ; perhaps the next day she 
would go three hours or longer ; and again the varia- 
tion might be as great during different parts of the 
same day. Eliminating other causes, I attributed this 
to the amount of urine which was contained in the 
bladder, varying at different times, and found that 
when a certain limit was reached the call was impera- 
tive. I demonstrated with the syringe that when the 
amount of fluid in the cavity was more than three 
ounces then the desire to empty it was pronounced, and 
four ounces produced intolerable pain. As the pa- 
tient was now quite strong, I began systematic dilata- 
tion by hyperdistention, and also instructed her to 
retain the water just as long as possible. Following 
out this course produced the most gratifying results. 
The progress was slow but steady. 

In July she could with very little discomfort, re- 
tain the urine an hour after she first felt the desire, 
and after having been one year under treatment, she 
could attend to all her duties, social and domestic, free 
from any disturbance from her bladder. She usually 
rose once during the night, but not always; and dur- 
ing the day the intervals were no more frequent than 
normal. There has been no relapse. 

The treatment of this case is that which I have 
found most uniformly successful in inflammatory lesions 
of the urethra. It is the application of a strong, 
almost caustic, solution of nitrate of silver through the 
speculum directly upon the seat of the disease. 

Case III. Retention of urine as a neurotic mani- 
festation, with cystitis and subsequent malignant dis- 
ease of the vulva, surrounding and including meatus. 

Mrs. C, age thirty-seven, May 11, 1887, was re- 
ferred to me, with the history that three weeks pre- 
viously (April 18th) there was stoppage of urine, 
accompanied by bearing-down pains. This had never 
before occurred. The urine was drawn, but stoppage 
occurred again the next day. In short, the catheter 
had been required seven or eight times during the 
three weeks. Upon all other occasions the act had 
been perfectly normal. The closest questioning failed 
in eliciting any reason why the urine should pass at 
one time and stop at another. There was never any 
pain. The time of day or night, the condition, exer- 
cise or rest, none of these were disturbing factors. 
Once started, the stream always continued until the 
bladder was empty ; but unless it started freely and 
immediately, neither straining or any of the usual aids, 
such as using water, etc., were of any avail. The 
only symptom the patient felt was "a kind of clicking 
feeling," and then the stream would not come. There 
was no uterine lesion. 

It was difficult not to attribute the condition to some 
material obstruction as the patient was apparently as 
free from nerves as any woman one could meet, — a 



large, strong woman in the best of physical health. 
Since her catheterization the urine, she noticed, had 
become cloudy, and I found it full of pus. Evidently 
she now had cystitis, but improved decidedly with 
proper treatment. I could find no local lesion what- 
ever by most careful endoscopic examination. There 
was no retention and no treatment for the next five 
weeks. Then, in consequence of living some days in 
the midst of fresh paint, as she thought, she had stran- 
gury and retention. Again a month's freedom and one 
day's retention. Without ether I dilated until I could 
easily pass my finger into the bladder, which I ex- 
plored thoroughly with curette, forcep and finger, but 
with former results. Following this, there was an 
interval of four months of freedom ; then the catheter 
was once required ; then two months' rest again. This 
brought the time to January, 1888. In examining, 
now for the first time, I thought there was some spasm 
at the neck of the bladder, so, January 18th, under 
ether, a most thorough dilatation was made, and the 
bladder and urethra explored in every way, but with 
entirely negative results. However, the patient was 
greatly relieved, and nothing more was heard of stop- 
page until January 18, 1889, just one year to a day 
from the last decided operation ; then occurred reten- 
tion. So matters went along through the summer. 
Occasionally, following a day of overfatigue or some 
severe mental strain, the urine would have to be 
drawn. There was no regularity. 

The patient occasionally wrote to me; but having 
made up my mind that the trouble arose from some 
neurotic condition and would continue as long as the 
cause, I refused to do anything more; but in Novem- 
ber, she appeared, stating that for a week past she had 
not been able to pass any urine, except it were drawn. 
Although the condition of the urethra and bladder still 
seemed normal, I noticed on each side of the meatus, 
and extending in a less marked degree above and below 
it, a hyperplasia of the vulva tissue, which seemed 
quite indurated at the base. This increased rapidly, 
and was extending up the under surface of the urethra 
into the vagina. A piece submitted to Dr. Whitney 
was reported upon as follows : 

Boston, January 2, 1890. 
Dear Doctor: — I have examined the specimen from 
the meatus received from you from the Free Hospital. 
It is composed of a connective tissue base, covered by 
thickened and irregular masses of epithelial cells. In gen- 
eral, the growth has the aspect of a papilloma, but in one 
place the cells have a tendency to dip into the tissues of 
the base. I am suspicious that it will recur. 

Yours truly, W. F. Whitney. 

I operated upon this thoroughly, removing all the 
diseased tissue. During convalescence retention oc- 
curred once, but ceased as soon as the dressing of 
iodoform was omitted. 

I last saw the patient about a fortnight ago, and she 
reports that, at irregular intervals, the catheter has 
been necessary. I have given her a full-sized No. 30 
bougie to use with regularity, hoping in time to over- 
come the trouble with the sphincter. 

The nature of the case in one way is plain to me, 
that is, that many of the occasions when resort to the 
catheter has been necessary, are hysterical in their 
origin. But why the first retention in a woman whose 
mind, so far as can be told, has never been directed 
towards her bladder? There has been no attempt to 
win sympathy. The more I treat her the more last- 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL 



65 



ing the relief; and yet neither I nor the gentlemen 
who have seen her with me have been able to find, 
either in the urethra, bladder or reproductive organs, 
any condition that would suggest a mechanical or 
reflex cause. 

The occurrence of the malignant disease I regard 
as a coincidence merely. It is in this situation, an 
extremely serious condition, I have seen two, possibly 
three, similarly situated ; and these have been more 
ulcerative in their character than this. Although I 
cut and burned thoroughly, yet I cannot but feel there 
is the strongest liability to return of the disease. 

I have regarded .the development of malignant dis- 
ease as a coincidence merely, but 1 am reminded by it 
of the development of a similar condition about an 
artificial vesico-vaginal fistula in a patient whom I had 
the opportunity of seeing with Dr. Forster. This 
raises the question in my mind as to how far the re- 
peated dilatation might have been responsible for it. 

Case IV. The tendency to the formation of vil- 
lous growths in chronic cystitis is rare, but even less 
common is it to meet with this condition in the urethra. 
I have seen it in but a single case, and in this asso- 
ciated with distinct fissure at the neck of the bladder 
and caruncle at the meatus. The cause of the trouble 
here was evidently mechanical, the cervix of a retro- 
verted and immovable uterus being crowded hard 
against the urethra. 

Mrs. W., age thirty -nine, consulted me first in June, 
1887, for relief from constantly increasing frequency 
of micturition, accompanied by pain, tenesmus and 
bloody urine. The pain was of cutting character, 
and extended up both sides of the pelvis to the back. 
When it was possible to pass the water in a standing 
position the pain was diminished. Under no circum- 
stances could the urine be retained if the inclination 
to pass it had been felt, and two hours was the maxi- 
mum interval between the acts for several months 
past. The symptoms dated back about two years, but 
then the onset had been gradual. The urine was quite 
clear, except for the presence of some free blood. The 
patient had been told that all her troubles were due to 
the caruncle ; but as this had been removed several 
times without relief, there was evidently some further 
lesion. 

Under ether, by the endoscope the urethra was seen 
to be covered with varicose and dilated blood-vessels 
in villous outgrowths from the meatus to its junction 
near the bladder. They stopped abruptly here, but 
there was a deep fissure at the vesical neck upon the 
lower side. The urethra was thoroughly dilated, its 
surface scoured and scraped, and painted with a strong 
solution of argentic nitrate. The walls of the bladder 
were hypertrophied, and the cavity would contain about 
three ounces. This treatment was followed by the bi- 
weekly injection of a weak solution of nitrate of silver 
and suppositories ; but the latter, as in most of the cases 
that I have seen, appeared rather to increase the pa- 
tient's discomfort, and their use was abandoned. 

At the same time, I attempted replacement of the 
uterus, but this was too irritating, and except the em- 
ployment of a single glycerine tampon placed so as to 
relieve the urethra as much as possible from pressure 
of the cervix, was abandoned. The patient steadily 
gained, except in the frequency of micturition which I 
attributed to the same cause largely as in Case II, 
namely, a contracted bladder. Systematically dilating 
it by hyperdistention, I had the satisfaction of over- 



coming this condition, and in September the patient 
was so well that she ceased attendance! against advice, 
as I felt sure the cervix would again set up trouble. 

In .January, 1888, the danger-signal of the cutting 
pain on micturition forced the patient to come again 
for treatment. I found two patches, each about the 
size of a split pea, midway of the urethra, showing the 
characteristics of a subacute urethritis. Willi cocaine 
as an aiuesthetic these were quickly dissipated ; and at 
the same time, by packing with great care, I was able 
to lift the uterus enough to free it from the pressure 
of the cervix. Since that date the patient has been 
perfectly well except for the slight local irritation of 
the caruncle, which has recurred twice. Should it 
again appear, I shall make a thorough dissection to 
remove entirely its base. 

It was interesting here to follow the gradual and 
steady improvement that accompanied the treatment. 
Few, if any, classes of cases are more exhausting to 
the nervous strength of the patients than these of ves- 
ical disturbance, and the reaction of the local and ner- 
vous conditions upon each other are most unhealthy. 

This case is one in which drainage through a vesico- 
vaginal or urethro-vaginal fistula would have been re- 
sorted to, I think, by many operators ; but, as it was 
possible to give the patient all the necessary attention, 
it seemed to me the more conservative course was the 
better. Despite all that may be said in their favor, 
fistula? put patients in uncomfortable relations to them- 
selves and their surroundings ; and one should, I feel, 
hesitate, and try many conservative lines of treatment 
before subjecting a patient to their annoyances and 
discomforts. 



THE INFLUENZA EPIDEMIC AS OBSERVED 
AT THE BOSTON LYING-IN HOSPITALS 

BY CHARLES M. GREEN, M.D. 

The cases of influenza observed at the Boston 
Lying-in Hospital during the late epidemic were 
neither numerous nor severe. But no unusual com- 
plication of the puerperal state is devoid of interest, 
and it has therefore seemed worth while to examine 
tbe clinical history of these cases with a view to the 
lessons which they may teach. 

The first seizure of the epidemic was observed 
December 24, 1889; the last, January 22, 1890. 
During this period of about a month there were fifty- 
two women in the hospital, and among this number 
there were seven cases of la grippe, or 13.4%, — a 
small proportion probably compared with that ob- 
taining in the community at large. 

Case I. Normal primiparous labor, December 20, 
1889. Convalescence normal until the morning of 
the fourth day, when the temperature was 99° F., 
and the patient did not feel well. Evening tempera- 
ture 102°, pulse 90 ; complaint of pains all over, with 
fulness of the head and some coryza, but no sore 
throat and no cough. Lochia abundant and sweet ; 
no tenderness over the uterus. Early next morning 
patient had a chill, and temperature rose to 102.4°, 
but later dropped to 100.4° ; erening temperature 
101°, pulse 106. After the chill patient was given 
quiuiae sulph. gr. x ; but she received no other treat- 
ment except occasional mild aperients or enemata. 
The temperature fell gradually, was normal on the 

> Read before the Obstetrical Society of Boston, April 12, 1890. 



56 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 17, 1890. 



morning of the ninth day, and the patient left the 
hospital well five days later. 

Case II. Normal multiparous labor, December 
26, 1889. Convalescence normal until the evening of 
the fifth day, when the patient had a well-marked 
chill, the temperature rising from 99° to 102.4°, and 
the pulse from 70 to 112: the right breast was some- 
what tense and painful and there was some cough. 
Next morning the temperature was 99°, pulse 72; but 
in the forenoon there was another chill, with pulse 
and temperature 84 and 100.4° respectively. There 
were no symptoms pointing to any trouble about the 
uterus, nor was the tense breast considered sufficient to 
account for the chills. That evening the pulse was 



116, and the temperature rose to 104° : ten grains of 
antipyrine were then given, and the next morning the 
pulse had fallen to 88 and the temperature to 99.8° : 
the next day pulse and temperature were normal, and 
there was no further disturbance. On the twelfth 
day, however, when the mother was convalescent, the 
baby was seized with coryza, conjunctivitis and bron- 
chitis and presented a perfect picture of the catarrhal 
form of the epidemic. This was the only case ob- 
served among the infants in the hospital. 

Case III. Normal primiparous labor, December 
27, 1889. The first stage was tedious, and the patient 
was rather exhausted, as may be inferred from the 
pulse and temperature, which did not fall to normal 
till the morning of the third day from the beginning 
of labor. On the morning of the fifth day of the con- 
valescence the temperature was 99° ; in the evening it 
was 101.4°, and there was complaint of headache and 
backache : lochia normal. In three days these symp- 
toms had disappeared and the temperature was nor- 
mal. 

Case IV. A normal primiparous labor, December 
22, 1889, and an uneventful convalescence, except 
from toothache, until the fourteenth day, when the 
morning temperature was 102.8° and pulse 100. Later 
in the morning, there was a chill and the temperature 
rose to 104°, the patient complaining of pains in the 
head and back. She was given ten grains of antipy- 
rine, kept in bed, and in two days pulse and tempera- 
ture were normal. 

Case V. Normal primiparous labor and normal 
convalescence until the sixth day when the patient 
did not feel well, although the temperature and pulse 
were normal. Two days later the breasts were cakey 
and were rubbed with camphorated oil. Next even- 
ing the patient had a chill and the temperature rose to 
103.4°; there was headache. Next morning the tem- 
perature was normal and there was no further dis- 
turbance. This may not have been a case of grippe, 
but it had that appearance ; and it did not seem that 
the subsiding tension of the breasts could have caused 
the symptoms. 

Case VI. Kasy primiparous labor, January 9, 
1890. On the fourth day there was some headache; 
temperature normal ; but on the sixth day the temper- 
ature rose to 103° in the afternoon, after quite a 
severe chill. There was some pain in the thighs, but 
no catarrhal symptoms and no evidence of sepsis. On 
the following day the morning and evening tempera- 
tures were 99.5° and 102°. A macular eruption with 
an occasional pustule appeared on the left breast. 
Next morning the eruption was more extensive, in- 
vading the axilla and passing around on the back. 
Morning and evening temperatures 100.8° and 100.4°. 



Next day the temperature was normal, and two days 
later the eruption was disappearing. 

Case VII. Rapid, easy primiparous labor, Janu- 
ary 10, 1890. Convalescence normal until the even- 
ing of the fifth day when the temperature rose to 
100.6°, with no other symptoms. Next morning a 
slight macular eruption with an occasional pustule 
appeared on the right breast, the appearances being 
similar to those reported in Case VI. In two days 
the temperature was normal. In this case the eleva- 
tion of temperature was not marked and the constitu- 
tional disturbance not very marked; but the eruption 
and rise of temperature resembled that observed in 
Case VI who occupied the next bed but one in the 
same ward, and the case was thought to be a mild 
seizure of la grippe. 

Of these seven cases it may be said that the symptoms 
were mild for the most part : in five cases there were 
one or more chills and decided elevation of pulse and 
temperature. In two cases there was a macular and 
pustular eruption : in general the symptoms were 
headache and backache, malaise with coryza and 
cough ; but the catarrhal symptoms were mild, except 
in the case of the baby previously reported. In no 
case was either nausea, vomiting or diarrhoea ob- 
served. 

No patient entered the hospital while suffering with 
influenza, so that no opportunity occurred to observe 
what effect, if any, the disease might have on the 
progress of labor. Neither was there any instance of 
premature labor induced by the epidemic influence. 
There were several cases, however, who entered while 
convalescent from the grippe, whose labor and puer- 
perium gave evidence of preceding prostration. 

The most serious feature of the epidemic, from the 
physician's point of view, was the apprehension occa- 
sioned by chills and sudden elevations of temperature. 
In puerperal convalescence such phenomena cannot fail 
to excite alarm until the diagnosis is clear as to whether 
the cause is a transient and unimportant one, or 
whether it is to be attributed to septic absorption. In 
each case, therefore, great care was exercised to accu- 
rately explain the changes in temperature before reach- 
ing a diagnosis. 

Such being the history of the epidemic among the 
patients, let us briefly examine the experience of the 
other members of the household. The regular com- 
plement of attendants embraces six day, and three 
night, nurses; but during the epidemic there was one 
vacancy among the nurses, and numerous substitutes 
were employed as occasion required. Of the eight 
regular nurses four succumbed to the epidemic ; and 
one night nurse was sick enough to have done so, but 
pluckily attended to her duties. Accurate histories 
were not kept of the nurses' sicknesses ; but they were 
all sicker than any of the patients, with perhaps one ex- 
ception. One nurse had an evening temperature of 105°, 
was delirious during the night, and required the attend- 
ance of a special nurse : there was backache and 
great prostration ; but the temperature gradually 
dropped and she was on duty in two days. Another 
nurse suffered with cough, tonsillitis and prostration 
for three or four days, with a temperature of 101° 
and 102°. Another had an evening temperature of 
103°, and was so prostrated by the attack that, al- 
though out of bed in two days, she was obliged to rest 
for a week before returning to duty. 

The Matron aud the Director of Nurses also sue- 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



57 



cumbed to the epidemic and were unfit for duty 
for two or three days. Two serving women were 
also seized, suffering like the others with high 
temperature, pains in the back and head and great 
general prostration. 

It is interesting to notice the contrast between 
nurses and patients suffering with the epidemic, in 
respect to the severity of their symptoms, — the lat- 
ter suffering much less severely than the former. 
This was obviously due to the fact that while the 
nurse was actively at work and frequently over- 
worked, the patient was quiet in bed, in favorable 
surroundings, and on a more or less restricted diet. 
It is reasonable to suppose that had the patients been 
in their own less hygienic homes, subjected to the mental 
annoyances and disturbances of family life in average 
tenement houses, and without trained nursing they 
would have suffered much more severely. Indeed, 
one of the out-patients, who had a long, difficult labor, 
terminated with forceps, was seized with la grippe on 
the sixth day and was very much sicker than any pa- 
tient in the hospital. Her evening temperature was 
104°, pulse 112, there was coryza, and severe general 
pains, even in the fingers. The evening temperature 
next day was 104.8°, and the following morning it 
had risen to 105.2; but from this point the fever de- 
clined and the patient made a gradual, but slow, re- 
covery. 



CASES OF CYSTITIS TREATED WITH SALOL. 1 

BV 8. L. ABBOT, M.D. 

Case I. On entering on my service at the Massa- 
chusetts General Hospital, March 1, 1888, 1 found in 
my female ward a patient who had been admitted on 
the 12th of February, suffering with severe uterine 
symptoms and pelvic cellulitis. On the 13th her urine 
had been drawn by a catheter for examination and 
was found to be normal in appearance, acid, of specific 
gravity 1,020, containing no albumen, depositing a 
slight sediment. 

The patient's general condition was bad. She was 
much emaciated, had severe night sweats, and the 
pelvic symptoms were severe with high temperature 
up to the 22d, when there was some mitigation of 
them, but micturition was frequent and painful. At 
this time the urine was pale, alkaline, of specific grav- 
ity, 1,014, and contained a small trace of albumen, a 
little blood and much sediment of pus and mucus, with 
triple phosphates. 

March 1st. Urine strongly ammoniacal, alkaline, 
otherwise about as on February 22d. 

Palliative remedies had given considerable relief, 
such as washing out the bladder with borax water, and 
rectal suppositories of morphia, — and acid, nitro-muria- 
tic "I xv had been given three times daily. On this day 
these remedies were omitted with the exception of 
washing out the bladder. Five grains of chlorate of 
potash were prescribed to be taken every two hours. 

March 2d. After the administration of eight doses 
of the chlorate, the urine was of normal color and odor, 
acid, of specific gravity, 1,018. It contained a slight 
trace of albumen, and there was some sediment con- 
sisting of a small amount of mucus and pus, a little 
normal blood, and fine and course granular and hyaline 
casts. The patient complained of pain in the lower 

1 Read before the Obstetrical Society of Boston, April 12, 1S90. 



left front chest, and some dry friction sounds were 
heard at this spot. The chlorate of potash was 
omitted. 

March 4th. The urine was again alkaline and in 
other respects as before the use of the chlorate. This, 
with the bladder washing, was resumed, as the chest 
symptoms had subsided, and an iron tonic was also 
prescribed. 

There was a gradual increase of strength and on the 
12th the record shows that the patient sat up five or 
six hours. 

On the 1 6th, the urine was reported as unchanged, 
the purulent deposit being one third of the whole bulk. 

March 17th. The patient had been up all the day 
before and was now complaining of moderate rheu- 
matic pain in the left shoulder and right side. Exam- 
ination of the chest gave a negative result. All the 
remedies were omitted, and salol gr. x was directed to 
be given three times daily. 

March 18th. Rheumatic pain relieved, and the urine 
has undergone a great change being acid for the first time 
in two weeks, pale, of specific gravity, 1,018; contain- 
ing a small trace of albumen and a greatly reduced 
sediment. The treatment was continued until the 24th 
when the urine was still acid and contained very little 
sediment. Salol omitted. 

March 25th. Urine alkaline again. As the patient's 
condition now admitted of a more powerful salicylic 
remedy, salicylic acid gr. v was prescribed, to be taken 
every three hours. 

On the 28th the patient was discharged well. She 
has been seen frequently since leaving the hospital, by 
my assistant Dr. Greene, and she continues well. 

Case II. Mrs. , a young married lady, called 

on me in the spring of 1888, complaining of symptoms 
which she regarded as uterine, from which she had 
been suffering for some days. On inquiry I learned 
that her most urgent symptom was very frequent mic- 
turition (" every five minutes " as she expressed it), a 
very small quantity of urine being passed at a time, 
greatly disturbing her sleep at night. The trouble 
was increasing and she asked for a uterine examination 
to determine the cause, supposing that there must be 
some displacement of the womb. I learned that sexual 
intercourse had occurred but twice during the month 
since marriage, without special suffering. 

On making an examination the sphincter vaginae 
was found to be spasmodically contracted and very 
tender to the touch, requiring some force to pass the 
finger beyond it. This having been accomplished, the 
uterus was found high up in perfectly normal position 
and condition, neither was there any vaginal tenderness 
above the os tincae except on the anterior surface where 
firm pressure towards the bladder caused much pain. 
There was and bad been no vaginal discharge, and the 
symptoms were clearly referable to the bladder. She 
could suggest no possible explanation of them. The 
urine at this time was strongly acid. Palliatives, such 
as the introduction of a few drops of four per cent, 
solution of cocaine within the vagina, alkalies, mor- 
phine suppositories in the rectum and hot hip baths 
gave some relief, the urine being alkaline on the follow- 
ing morning. 

On the next day the patient complained of loss of 
appetite, the tongue was furred, and there had been a 
chilly turn the day before followed by profuse sweat- 
ing; she had had intermittent fever in 1884. The 
urine was acid, specific gravity, 1,012, without appre- 



58 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 17, 1890. 



oiable albumen, contained abundant crystals of triple 
phosphate and muco-pus in large amount, constituting 
from a quarter to a third of the whole volume on 
standing. 

Two grains of sulphate of quinine were prescribed 
to be taken before each meal, and the other remedies 
were continued. 

On the next day, as there had been no recurrence 
of chills or sweating and the bladder symptoms were 
about the same, all remedies employed were omitted 
except the hip bath, and five grains of salol was pre- 
scribed to be taken every three hours. 

On the next day the patient reported very great 
relief, being able to retain the urine one hour at a time 
and micturition was much less painful. Urine acid, 
specific gravity, 1,014, still containing considerable 
muco-pus and bladder epithelium. From this time the 
symptoms rapidly improved, and the patient reported 
herself well on the sixth day after commencing the 
salol treatment. 

Case III. A widow lady past middle life, was taken 
in the middle of November, after getting chilled by 
standing some time in the street exposed to a high 
wind, with a severe attack of catarrh of the bladder. 
Painful micturition was very frequent by day and 
night. At first she was treated with alkalies and rectal 
suppositories of morphia which gave some relief. 
During the second week salol was prescribed in the 
dose of five grains to be taken three times daily and 
the alkali was omitted. On the third day the salol 
was directed to be taken four times daily, and bicar- 
bonate of soda in addition if needed. 

At the end of the week the urine was nearly natural 
and the micturition was painless, occurring but twice 
during the night and three or four times only during 
the day. In ten days after the treatment was com- 
menced the patient was entirely well. Three days 
before the conclusion of the case, an iron tonic was 
prescribed, as a slight attack of diarrhoea for one day 
had caused considerable weakness. 

This patient was very much impressed with the 
efficacy of the salol treatment, as a few years before 
she had had a similar attack much less severe in char- 
acter, under the care of an intelligent physician, during 
which she was confined to her bed for six weeks and 
required the constant attendance of a trained nurse ; 
while in the present instance she was able to lie on a 
couch during the last few days of her illness, and the 
care of her family servants was all that she needed. 



CASE OF EPITHELIAL CANCER IN A 
NEGRESS. 1 

BV ICDWARI) JACOB FORSTKK, M.D., 

Visiting Physician, Hnstnn City Hospital. 

INI v attention having recently been called to the 
rarity of carcinoma in negroes, I am lead to report a 
case which recently came to my service at the City 
Hospital. 

From the hospital records I condense the following 
history : Mary C, a full-blooded uegress, twenty- 
seven years old, born in Virginia, entered the hospi- 
tal February 4, 1890, for treatment for " falling of 
the womb." Family history negative. Had chills 
and fever when nine years old ; " inflammation of 
bowels," probably attacks of cellulitis, several times, 

1 Kph'1 boforn Hip Obstetrical Society of Boston, April VI, 1h!>0. 



the last three years ago. Menstruation regular, but 
profuse ; complains then only of dull pain in front 
passage. Has leucorrhcea. One child several years 
ago. No miscarriages. Denies intercourse for three 
years. No pain on micturition. Bowels constipated. 
General health good ; is well-developed and nour- 
ished ; would be called fat. 

Examination showed marked cystocele. Uterus in 
second degree of prolapse. Sound passes four and 
one-half inches. Bilateral tear of cervix without 
marked eversion of lips, a spot about the size of a 
silver quarter of a dollar on the left side of posterior 
lip encroaching upon the angle of the tear and extend- 
ing towards the cervical canal from which the mucous 
membrane is absent; very slightly excavated, and at 
the sides extending slightly under the mucous mem- 
brane. The appearance was unlike any epithelial 
growth I have ever encountered in this or any locality, 
and gave one the impression at first view that it might 
possibly be a syphilitic lesion. 

A piece the size of a ten-cent coin was excised, and 
sent to Dr. H. F. Sears, who returned the following 
report : " Microscope shows masses and threads of 
epithelial cells in connective tissue throughout speci- 
men — epidermoid cancer." 

On February 19th patient was etherized, and with 
the assistance of Dr. Haven, I amputated the cervix. 
First splitting the cervix on both sides of the vaginal 
junction, a large wedge-shaped piece was removed 
from each lip, the mucous membrane of the canal was 
stitched by a single silk suture on either side to the 
outside of the cervix, and the remaining portions of 
the lips united by ten silver sutures. An elastic 
ligature controlled all haemorrhage. The operation 
lasted one hour and ten minutes. Patient recovered 
well from ether. Antiseptic washes and pad used 
p. r. n. Catheter every six hours. . . . 

March 2d. Stitches all removed. Parts firmly 
united. Uterus found in normal position. After re- 
covery from the customary weakness attendant upon 
a fortnight's stay in bed. the patient was discharged 
at her own request on the 13th, and advised to visit 
occasionally the out-patient department. This advice 
I am told she has followed ; and Dr. Green or Dr. 
Haven can perhaps tell us of her present condition. 

While most all writers recognize and dwell upon 
the extreme frequency with which uterine fibroids 
are found in negroes, after a careful search, very little 
can be found written in regard to the frequency with 
which carcinoma affects them. That little is nearly 
if not quite all contained in a paper by Dr. Louis 
McLane Tiffany in Volume V of the " Transactions of 
the American Surgical Association" (1887), entitled 
" Comparison between the Surgical Diseases of the 
White and Colored Races." He says: "Of malig- 
nant growths, the ones most common are the sar- 
comata, and these are usually in relation with the 
skeleton. . . . Carcinoma is very rare in the ne- 
gro" ; and that during thirty-four months in the out- 
patient department of a general hospital where 4,930 
cases were treated, 34% of which were colored, no 
case is recorded of epithelioma of the face or lip of 
a negro. In his own practice, he can only call to 
mind one instance of epithelioma of the tongue in a 
negro. 

In the discussion which followed the reading of Dr. 
Tiffany '8 paper, Dr. E. H. Gregory, of St. Louis, 
stated that he had never seen cancer of the lower lip 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



59 



in a negro. Dr. W. T. Briggs, of Nashville, Term., 
said he thought cancerous affections were not so com- 
mon as in the white race. 

If we can judge by the omission to mention the ute- 
rus as a seat of carcinoma by these gentlemen who prac- 
tice where there is a large colored population and the 
meagreness of the literature of the subject, the situa- 
tion in the case just reported is certainly exceptional. 

Professor Baker, who first called my attention to 
this subject, I think, said he had not met with a case. 

Dr. C. M. Green who examined this case with me, 
remembers having seen but one other. 

Dr. D. W. Cheever told me yesterday that he 
could not recall having met with a case of uterine can- 
cer in a uegress. 

Dr. H. H. A. Beach in a note writes me: " In my 
own operating, I do not recall but two cases of epithe- 
lial disease among negroes, one of the lip and one of 
the labia majora, the former was a male subject." 

The rarity of cases like the one reported is, I trust, 
sufficiently shown to excuse me for having taken your 
time by giving the details of one which when occur- 
ring in women of our own race, we are unfortunately 
only too familiar. 

i£eport$s of £>otietie#. 



THE OBSTETRICAL SOCIETY OF BOSTON. 

CHARLES W. TOWNSKND, M.D., SECRETARY. 

Meeting April 12, 1890. 
Dr. Strong reported 

CASES ILLUSTRATIVE 01' SOME OP THE MORE UN- 
USUAL FORMS OF BLADDER DISEASE AMONG 
WOMEN. 1 

Dr. Davenport said that in many mild cases of 
urethral irritation the passage of a steel sound gave the 
same satisfactory result as with similar treatment in 
cases of mild urethritis in the male. He had never 
seen the villous condition spoken of by Dr. Strong. He 
mentioned a case where there was a vesical polypus 
hanging by a delicate pedicle. 

Dr. Abbot said that he was prompted by Dr. 
Strong's report of his cases to speak of several cases of 
cystitis which he had successfully treated with salol. 2 

Dr. Abbot also said that he had recently tested the 
power of salol in a case of severe acute gonorrhoea in 
a man, in which the dose of five grains was prescribed 
to be taken every two hours. The treatment was 
begun at the end of the second week of the attack. At 
the end of the third day the patient himself reduced the 
dose to two and a half grains every two hours, on 
account of the relief he had experienced, and at the 
end of five days of the use of this remedy the discharge 
was reduced to a small drop with almost complete relief 
to the scalding micturition. 

Dr. Abbot referred to the rapid elimination of this 
antiseptic by the kidneys, and mentioned an instance 
within his personal knowledge, in which a medical 
friend had taken a dose as an experiment, and detected 
its presence in his urine by a chemical test fifteen min- 
utes after. 

Dr. Minot was reminded by one of Dr. Strong's 
cases of a patient, thirty-five years old, unmarried, who 

1 See page 03 of the Journal. 
' See page 57 of the Journal. 



was always well till May 24, 1889, when she found she 
was unable to pass water. At the end of eighteen 
hours Dr. Minot catheterized her, and then found a 
large libroid tumor of the uterus, which did not, how- 
ever, press on the urethra, and he was puzzled to ac- 
count for the retention. The patient had remained 
well till yesterday, when it was again necessary to 
draw off the urine. The tumor had increased con- 
siderably, but still formed no obstacle to the introduction 
of the catheter. He supposed that the retention was 
a reflex phenomenon, but had never before met with 
such a symptom in cases of uterine fibroids. 

Dr. Richardson said that he had seen one similar 
case in a cook where four or five attacks of retention 
had occurred. 

Dr. Abbot had twice been called to cases of sudden 
inability to pass urine and found a fibroid of the uterus. 

Dr. Chadwick said that he was becoming more 
and more convinced that most cases of bladder trouble 
yield to general treatment, and that very few require 
iocal treatment. An examination is, however, essential 
in all cases. Caruncle, he thought, existed in a large 
number of cases without producing symptoms, hence 
its removal is not likely to give relief where there are 
symptoms of bladder irritability. There is no more 
common cause of frequent micturition than retrover- 
sion of the uterus, although it is doubtful how it acts. 

A recent case he had treated for cystitis when he 
found the cause to be stone in the bladder, the symp- 
toms were very non-suggestive. 

Dr. Blake thought that the symptom of sudden re- 
tention of urine in patients with uterine fibroid may 
not be so very uncommon, as he had taken care of two 
such cases, both patients being cooks, and he wondered 
whether the occupation had anything to do with it. In 
one of these cases it was necessary to pass a male 
catheter eight or ten inches before reaching the 
bladder. 

Dr. Strong in closing said that he agreed with Dr. 
Chadwick that very few cases require local treatment, 
but that an examination was in all cases necessary. 
Caruncles he found to be very common in the out- 
patient department of the Massachusetts General Hos- 
pital, occurring in perhaps one out of five patients. 
The small caruncles just inside the meatus are the ones 
that give trouble, the large external ones generally 
give rise to no symptoms. 

Dr. Blake mentioned a case of excessive irritability 
of the bladder which has lasted for two years, reducing 
the patient very much. The cause in this case was a 
urethral caruncle. 

Dr. Green read a paper entitled 

the influenza epidemic as observed at the 
boston lying-in hospital. 8 

The reader asked whether any of the members had 
seen labor brought on by an attack of influenza. 

Dr. C. E. Stedman said he had a patient in the 
eighth month of pregnancy who had a severe attack 
of influenza, but it did not bring on labor. 

Dr. Strong had a patient who had influenza and 
miscarried at seven and a half months. 

Dr. Green had a patient with influenza one week 
before confinement which occurred at the expected 
time. 

Dr. Edw. Reynolds spoke of cases supposed to be 
in labor, where it was found that the influenza was the 
9 See page 55 of the Journal. 



60 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[Jolt 1?, 1890. 



cause of the pain. One of his cases developed influ- 
enza the day after confinement. The baby four or five 
days later began to cough and have diarrhoea, dying in 
the course of a week. In another case the patient was 
taken with influenza the day before confinement, and 
the baby had diarrhoea beginning on the second day. 

Dr. Townsend said that one of his patients had 
influenza a week before she was confined, and the baby 
was born with symptoms which lead him to think it 
had congenital influenza. He would report this case 
at some future time. 

Dr. Richardson said that one of his patients had 
an attack of the grippe at the seventh month of pregnancy 
and was afterwards confined at the proper time. An- 
other case had a moderate attack of the disease at the 
seyeuth and a half mouth of pregnancy and miscarried 
on the third day. The infant was feeble, had snuffles 
and died in three days. 

Dr. Forster reported 

A CASE OF EPITHELIAL CANCER IN A NEGRESS. 4 

Dr. Strong had seen two cases of cancer in colored 
women in the last month. 

Dr. Edw. Reynolds had met with three such 
cases. 

Dr. Green showed a photograph of a placenta in a 
case of triplets. Also a photograph of a man who was 
born with but the stumps of all four extremities. 



AMERICAN NEUROLOGICAL ASSOCIATION. 1 

TRAUMATIC NEURO-PS YCHOSES. 

Dr. G. L. Walton read a contribution to this sub- 
ject, in which he dealt exhaustively with the questions 
of pathology and prognosis in injuries inflicted upon 
the nervous system by railway collisions and similar 
accidents. From the influence of Erichsen's views, 
functioual and organic injuries were, for a long time, 
indiscriminately classed together under the ambiguous 
and misleading term, spinal concussion, while a com- 
mon prognosis was given to all, leaving the student in 
doubt as to whether the worst or best results might be 
anticipated. To H. W. Page was due the credit of 
having elaborately corrected this inaccuracy and of 
sifting out the comparatively rare cases of organic 
spinal disease, whose sad course and prognosis had 
been so long allowed to overshadow and include the 
more common cases in which no demonstrable lesion 
existed. To the latter class, he had first applied the 
term traumatic neurasthenia. Dr. Putnam, in 1883, 
after reporting several cases of traumatic hemi-anses- 
thesia, had called attention to the importance of look- 
ing for evidences of typical hysteria in the chronic as 
well as in the acute stages of so-called spinal concus- 
sion. Among those who had early inclined toward 
the modified views regarding the effects of trauma on 
the nervous system, might be mentioned Dr. Dana, 
who, writing in 1883, had very appropriately added 
hypochondria to the two terms already applied. 
Spitzka had considered that spiual concussion could 
produce spinal irritation. These theories were in 
direct opposition to the idea advanced by Westphal, 
that a diffuse sclerosis was set up by the jar. This 

1 Report of tbe Sixteenth Annual Meeting, held at Philadelphia, 
June 4-6, 1890. Continued from page 42 of the Journal. 

• See page 68 of the Journal. 



view had many followers, both in Germany and 
America. In a recent work by Chreuger, of Chicago, 
it was proposed to give to these cases the name 
" Erichsen's disease." This writer had regarded the 
spinal sympathetic system as the starting point of 
the pathological process. Seguin, in " Sajous' An- 
nual " of 1889, considered organic injury to the ner- 
vous system a rarity as resulting from the forms of 
trauma under consideration. Without exhausting the 
literature of the subject, it might fairly be concluded 
that there was at present a very general, though not 
unanimous, tendency to abandon the theory of spinal 
concussion, and to regard the majority of the genuine 
cases as identical with already recognized functioual 
forms of disease, rather than cases of organic spinal 
injury. Dr. Walton's experience had lead him from 
the first to regard disease of the spinal cord resulting 
from trauma as of comparative rarity, when no dislo- 
cation or fracture had occurred, while Seguin's conclu- 
sion regarding the preponderance of the subjective 
symptoms, and the degree in which we were generally 
dependent on the patients, were fully justified by the 
majority of the cases which had come under the 
writer's observation. 

The President regretted that the two works deal- 
ing with this subject were open to the stigma of hav- 
ing beeu written for trade purposes. It was important 
in discussing the question to avoid anything but its 
clinical aspect. 

Dr. P. C. Knapp could not agree with the author 
of the paper in the position he had taken. Page had 
deliberately ignored most important neurological points. 
The theory of Charcot that many of these cases were 
hysterical was pretty well exploded. 

Dr. F. F. Pdtman thought there were but few per- 
sons who could carry out successfully a system of de- 
ception during a long and searching examination, 
much less through two such investigations. 

Dr. F. X. Dercum said that in his opinion there 
was a union of two factors. In some cases there ex- 
isted actual cause for painful back. It was remark- 
able how the same story would be repeated unsolicited. 
It required a person well-trained in the subject to re- 
late such symptoms. Then there would be diminution 
of the heart-beat, great awkwardness of movement, 
marked disorders of sensation, errors in locating points 
of contact, and many other mistakes which a healthy 
man could uot make. Many of these symptoms were 
such as the patients could hardly pick out for them- 
selves. It was immaterial whether the initial trouble 
was actual organic disease, or profound functional dis- 
turbance, the fact remained that these people did not 
recover. 

Dr. W. R. Birdsall agreed that it was the most 
conservative view to say that there was possibly a 
traumatic lesion in a certain number of these cases, 
still he thought the great majority showed functional 
phases. The chief element in the production of these 
conditions, even if there existed organic changes in 
addition to the functional disturbance, was emotion, 
and psychic shock. 

Dr. D. Inglis did not agree with the author of the 
paper. The profession had to take one position or the 
other in deciding whether these cases were organic or 
functional, and then a jury might do as it thought fit. 
He also proposed a method for testing hyper-sensitive 
areas. 

Dr. C. K. Mills thought there were at least three 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



61 



classes of cases resulting from injury: (1) pure 
fright; (2) cases in which the indications were clear 
that fracture or haemorrhage or other serious lesion 
had takeu place; (3) cases in which the symptoms 
presented were both objective and subjective, with a 
prepoudrance of the latter. He thought that the ex- 
istence of some organic lesion, whether myelitis, or 
the result of haemorrhagic pressure upon some delicate 
part of the nervous system, would explain many of 
the symptoms peculiar to this class. 

A CASE OF COMPLETE PARAPLEGIA CURED BY 
TREPHINING. 

Dr. F. X. Dercum presented a patient upon whom 
trephining of the upper dorsal vertebral arches, for 
paraplegia and complete paralysis of the sphincters, 
had been performed, resulting in complete recovery. 

The President in commenting on this unique case 
characterized it as almost unprecedented. 

Dr. Putman said the case seemed to be one of 
unusual iuterest, and thought that they must all wel- 
come such advance in the surgery of this region. The 
speaker had reported several cases, in which he 
thought exploratory operation might have been done 
with benefit. 

Dr. V. P. Gibney said he was extremely delighted 
with the brilliant results in this case. From the way 
the patient now held his head, he should be inclined 
to look upon the case as an old Pott's disease. Sur- 
geons had been chary of operating in these cases, 
though the operation was comparatively an easy one, 
at least, simple in detail, and with the aseptic and anti- 
septic methods of to-day, it was practically impossi- 
ble to have bad results, and recovery was to be ex- 
pected. 

The President said they would be glad to know 
to what extent the present position of the head corre- 
sponded with the position before the operation. 

Dr. Dercum said the position was at that time nor- 
mal. He considered the present inclination of the 
head forward as due to loss of certain attachments of 
the trapezius muscles at their points of insertion into 
the spinous processes. There might have been a 
rheumatic element in this case affecting the meninges 
of the cord. 

The President said he would like to ask Dr. 
Gibney as to the deformity in which there was ex- 
treme bending forward of the neck. 

Dr. Gibney said this condition sometimes obtained 
to an indefinite extent. It might be a senile kyphosis. 
Though it would perhaps be urged that Pott's disease 
at such an age was impossible, yet as a matter of 
fact there were quite a number in whom it developed 
after fifty or sixty, following a fall or injury. The 
position of this man's head might be due to loss of 
substance of the bodies of the vertebrae. 

Dr. W. N. Bullard thought the rapid advance in 
spinal surgery should lead to more definite conclu- 
sions as to the cases of Pott's disease suitable for 
operation. 

Dr. B. Sachs said he was gratified to hear the re- 
port of such a case as Dr. Dercum had presented. It 
went to show that many of the cases hitherto operated 
upon had been badly chosen. When cases could be 
selected, statistics would probably be more encourag- 
ing and favorable. 

The President thought that the theory of rheuma- 
tism in this case could not be entirely disposed of. 



Dr. C. L. Dana said he did not share the optimistic 
view which Dr. I'utman had advanced, and should be 
sorry to start a boom in spinal surgery. If the his- 
tory of all the operations already performed in this 
field was known, he thought they would be disposed 
to follow the conservative suggestions of Dr. Sachs, 
and would deal only with selected cases. 

Dr. Gibney said that he did not by any means de- 
sire to start a boom in spinal surgery. What he had 
meant by an easy operation was, that in these old 
cases of Pott's disease the spinous processes were very 
prominent, and the soft parts were thin and readily 
got at. Cases should always be very carefully 
selected. 

Dr. Dercum thought that the proper cases were 
difficult of selection, and it was only now and then 
that success could be hoped for. He regarded the 
results in his case as fortuitous. 

A case of locomotor ataxia associated with 
nuclear cranial nerve palsies, and with 
muscular atrophies. 

Dr. Frederick Peterson reported the history of 
the above-named case. The patient had been under 
the writer's observation since March, 1890, but the 
features of the case had been previously described, by 
Dr. Seguin, in the Journal of Nervous and Mental 
Disease for May, 1888. It was the first of five cases 
of opthalmoplegia reported by that author. As there 
had been so many new developments in the patient's 
condition during the past four years, that it was 
thought best to briefly outline the history from the 
first observations made up to the time when he came 
under the writer's notice. M. J. T., now thirty-seven 
years of age, had had a chancre and secondary symp- 
toms fifteen years ago. In 1882, he had discovered 
one morning dimness of vision and external strabismus 
of the left eye, with diplopia. A little later he had 
shooting pains in the legs, occasionally in the arms. 
In 1883, he had a momentary loss of consciousness, 
and fell, cutting his head. His left testicle also be- 
came swollen and hard during this year, and he was 
under specific treatment at Hot Springs for some time. 
In 1884, he had partial double ptosis. In the right „ 
eye, the internal rectus, inferior oblique and sphincter 
iridis were paralyzed, and the superior and inferior 
recti feeble. The other muscles were normal. In 
the left eye the muscles supplied by the third nerve 
acted variably and feebly. The other muscles were 
normal. Both pupils were completely motionless to 
light and accommodation, the left larger than the 
right. Opthalmological examination resulted as fol- 
lows: R. V. = f§ : f-gw + L. V. = fft : fgw 

-j- -jij. R. A. = L. A. =s -j^. There was no 
lesion of the optic nerves. 

The left cheek was a little inactive, and there was 
a mild paresis of the right hand. Dynamometer : 
R. = 42 — 44, L. =: 45. No Romberg symptom. 
Knee-jerks exaggerated. Both feeble and involuntary 
micturition. In 1885, the ptosis was nearly total on 
the left, but partial on the right side. In the right 
eye, the condition of the muscles had remained un- 
changed, while in the left, they had improved so much 
that they acted almost normally. Some paresis and 
atrophy of both temporal and both masseter muscles 
was now noted. In 1886, when lost sight of by Dr. 
Seguin, the ptosis was a little greater, the bladder still 
paretic, and the masticatory muscles unchanged. No 



62 



BOSTON MEDICAL AND SURGICAL JOURNAL. [Jtjly 17, 1890. 



marked facial paresis. The knee-jerks, previously 
exaggerated, had fallen to about normal. Dr. Seguin, 
writing in 1888, had said of this case, that some of the 
symptoms seemed to justify a suspicion of incipient 
" posterior spinal sclerosis." 

Since 1886 until the present time, there had been 
gradual progress in the disease. The present condi- 
tion of the eyes was as follows: Iu the right, all of 
the muscles external and internal, except the rectus 
externus, were completely paralyzed. The rectus ex- 
ternus was paretic, and when moved exhibited clonic 
spasm. In the left eye, there was almost complete 
opthalmoplegia externa et interna. Both pupils were 
widely dilated, equal and immobile. Divergent squint 
of right eye. Vision was unchanged. As far, there- 
fore, as the innervation of the ocular musculature was 
concerned, we had now lesions affecting both third 
nerves, both fourth nerves, and both sixth nerves. 
The weakness and atrophy of the masseter and tem- 
poral muscles was more pronounced. These muscles 
did not react to Faradism. There was no anaesthesia 
of the face. The tongue deviated slightly toward the 
left. The electrical reactions iu the face and tongue 
muscles were normal. There was still some evidence 
of weakness in the right hand. The patient had now 
well-marked tabes dorsalis. There was marked ataxia 
of all four extremities. He could not walk without 
assistance. The knee-jerks had disappeared. There 
was numbness, anaesthesia and analgesia in all of his 
ringers. In both legs, as far as the knees, there was 
almost complete tactile anaesthesia. Muscular sense 
was entirely lost iu both feet. Iu addition to other 
symptoms, which pointed out fully-developed locomotor 
ataxia, the patient presented some very interesting 
trophic disturbances. Beside that of the muscles sup- 
plied by the motor branches of the trigemini already 
described, there was wasting of the right trapezius, 
with a degenerative reaction. In the left upper ex- 
tremity there was complete paralysis of the two long 
exteusors of the phalanges of the thumb, and atrophy 
and paresis of the abductor minimi digiti aud of all 
of the interossei and lumbricales, with degenerative 
reaction. On the right side there was almost com- 
plete atrophy of the opponens and abductor pollicis. 
Considerable wasting was apparent in the adductors of 
both thighs, more upon the right side. 

The main features of the case might be summarized 
as follows : The patient had had a number of bilateral 
motor cranial palsies, namely, the third, fourth, fifth 
and sixth nerves. He had also exhibited slight traces 
of crossed paralysis for more than four years. Loco- 
motor ataxia had been developed, as was shown by the 
occurrence at one time of lightning pains, aud by the 
presence now of ataxia, widely distributed anaesthesias, 
failure of knee-jerks, and ocular, vesical and anal 
symptoms. Finally, he had presented marked trophic 
changes iu numerous muscles. As to the morbid pro- 
cesses underlying these various manifestations, there 
was in the first place undoubtedly a sclerosis of the 
posterior columns of the spinal cord. The opthal- 
moplegia was, of course, nuclear. Read in one way, 
the symptoms on the side of the cranial nerves, taken 
in conjunction with the muscular atrophies and paral- 
yses elsewhere, certainly very closely resembled the 
syndromes so well described by Dr. Sachs in a paper 
last year under the title of " Polio-encephalitis Supe- 
rior, and Polio-myelitis." The most important matter 
to be settled in this case was whether the muscular 



atrophies were due to peripheal or central lesions. 
Speculation upon the question would seem to be of 
very little utility, and its solution must be left to the 
hoped-for autopsy. It had been assumed by a num- 
ber of authors that total paralysis of all of the muscles 
supplied by the third nerve, implied not a nuclear but 
a nerve-trunk palsy. In the writer's case all of the 
muscles of both third nerves were totally paralyzed, 
including both irides ; and yet there was every reason 
to believe that the palsies were nuclear. It would at 
least be difficult to conceive of a lesion at the base of 
the brain so widely affecting the trunks of the third, 
fourth and sixth nerves, and the motor portions of 
both trigemini, yet permitting the escape of the sen- 
sory portions of the latter. 

Dr. C. K. Mills thought that the case might be 
some peculiar, irregular form of syringo-myelia. 

Dk. E. D. Fisher suggested that the case was one 
of amyotrophic lateral sclerosis. 

Dr. Sachs thought the case very closely resembled 
one of his, in which the diagnosis was polio-encepha- 
litis superior and polio-myelitis, although there were 
more symptoms of tabes dorsalis than in his case. 

Dr. Peterson did not think the case one of syrin- 
go-myelia owing to the very symmetrical distribution 
of the nuclear palsies, and because there was no an- 
aesthesia of the upper extremities, face or trunk. 

MULTIPLE NEURITIS, OR BERI-BERI, AMONG SEA- 
MEN. 

Dr. J. J. Putnam reported about twenty cases of 
a disease resembling beri-beri, but possibly another 
form of multiple neuritis, occurring among fishermen 
in northern latitudes, and referred to a similar series 
of cases reported by Dr. F. C. Shattuck in 1881. 
By correspondence with physicians in the sea-port 
towns, Dr. Putnam had ascertained that, besides the 
larger epidemics, sporadic cases occurred from time to 
time. One physician had reported frequent cases of 
swelling and numbness of the hands attributed to 
handling fish. The influence of alcohol and the metal- 
lic poisons could be excluded ; and since the outbreak 
occurred only now and then, the influences to which 
the seamen were habitually exposed could hardly be 
considered as the whole cause, though insufficient food 
had seemed to play a part in some instances. Most 
of the patients had recovered, but some had died. 

Dr. Gray asked if these men carried large quanti- 
ties of ice, because he had seen neuritis following the 
handling of ice, which had promptly subsided if this 
cause was removed. 

Dr. Birdsall asked as to the amount of air sup- 
plied to the hold of these vessels and to the seaman's 
quarters. Cases recently reported to him had led to 
the impression that the men who had died had been 
especially exposed to bad air in the hold, while those 
in good quarters had escaped. He agreed also that 
cold was an important element in the production of 
nearly all forms of neuritis. 

Dr. Heuter asked if the diet had been of fish. 

Dr. Putnam said that fish had not been the diet, but 
salt pork, sometimes fresh vegetables and fresh meat. 
But in one of the worst cases it had been salt pork. 

ON CASES OF POSTERO-LATERAL SCLKROSIS, WITH 
SPECIAL REFERENCE TO THE PATHOLOGY OK 
THE DISEASE. 

Dr James J. Putnam referred to a series of eight 
cases of similar character, presenting the symptoms 



Vol. CXXIIT, No. 3.] BOSTON MEDIO A h AND SURGIOAL JOURNAL. 



of '• combined sclerosis " of the spinal cord, which he 
had seen during the past few years, and reported four 
of them, in which he had examined the cord micro- 
scopically. All the cases of the series, though differ- 
ing in some respects, resembled each other as follows : 
all the patients were past middle life; all were either 
amemic or in a state of poor nutrition. The symp- 
toms in all had consisted in both motor and sensory 
disorders in all four limbs, sometimes associated with 
incoordination, sometimes not. The knee-jerk was 
exaggerated in all but two or three ; in those it was 
absent. Tabetic pains were present in one case only. 
Anatomically sclerosis was found in the posterior and 
lateral columns, varying iu exact position. In almost 
every case the posterior change had seemed the older 
and most intense. Besides the " typical " sclerosis, 
there was evidence of a more recent process, charac- 
terized by granule-cell formation, and the breaking 
down of the nerve-tubes so as to form circular or oval 
spaces. This new process was developed on the 
borders of the older change. The gray matter of the 
cord was more or less affected, and the nerve roots 
in about the same degree. The cases had all run a 
rapid course, terminating, after one to four years, in 
death, preceded by paraplegia due to non-inflammatory 
softening. Next to inherent structural weakness, as 
an etiological factor, came impaired nutrition and 
toxic influences. The importance was pointed out of 
recognizing, and attempting to meet, the partial 
courses of the disease, of which several might be 
present at once. As special stigmata of degeneracy 
in these four cases, the writer referred to the mental 
condition and family history of several of the patients ; 
to the remarkably abnormal shape of the cord in one ; 
the small size of the dorsal gray matter in another, 
and the presence of a second central canal iu a third. 

Dr. S. G. Webber cited the case of a young girl, 
who, from excessive walking, had developed decided 
symptoms of lateral sclerosis. This patient had grad- 
ually recovered the use of her limbs. 

Dr. Putnam, replying to Dr. Dercum, said that 
there had been no serious involvement of the internal 
organs in any of the cases and no typical Bright's 
symptoms. These patients were so largely women 
that he could not but assume the existence of some 
lesion from impaired nutrition and constitutional taint. 

THE PATHOLOGICAL FINDINGS IN DR. W. A. HAM- 
MOND'S CASE OF ATHETOSIS. 

Dr. G. M. Hammond read a report on the patho- 
logical findings in the original case of athetosis on 
which Dr. W. A. Hammond's description of athetosis 
was based. After briefly referring to the case, Dr. G. 
M. Hammond stated the portion involved in the lesion 
had consisted of fibrous connective tissue. Topograph- 
ically the lesion was a lengthy one in the antero-pos- 
terior direction, parallel in its short axis with the 
internal capsule. Its posterior end had invaded the 
stratum zonale of the thalamus on its posterior third 
and the posterior half of the internal capsule. In its 
anterior extension it had crossed the capsule, invading 
the posterior third of the outer articulus. The author 
called attention to the fact that the motor tract was 
not implicated in the lesion, and argued that this case 
was further evidence of his theory that athetosis was 
caused by irritation of the thalamus, the striatum or 
the cortex, and not by a lesion of the motor tract. 

Dr. E. C. Spitzka reported a case in which the 



lesion was found to be in the same situation as in Dr. 
1 lammond's case. 

I)k. K. ('. Secijin presented a paper on 

ATHETO— CHOREIC SPASM OF THE RIGHT SIDE OK 
THE BODY. 

The post-mortem had shown a glioma of the left 
thalamus opticus and adjacent internal capsule. Dr. 
Seguin's views were that all cases of athetoid and 
choreiform movements following hemiplegia were 
due to lesions involving the thalamus and adjacent 
capsule. 

(To be continued.) 



THE NEW YORK ACADEMY OE MEDICINE. 

Stated Meeting May 15, the President, Alfred 
L. Loomis, M.D., in the chair. 

Dr. L. L. Seaman, read a a paper on 

THE AUSCULATORY PERCUSSOR. 

This is an instrument constructed on scientific 
principles, by which, as explained by him, the prac- 
titioner is enabled to realize and delicately discrimi- 
nate the percussion note, while adding to ordinary 
percussion the value of mediate auscultation ; thus se- 
curing a trustworthy and explicit tonal reading of 
internal conditions. In conjunction with the Edison 
phonograph it also furnishes an instrument by means 
of which percussion notes may be accurately registered. 
When in use the object end of the instrument is 
placed directly over the area under examination. The 
thumb raises a lever which, when at a given height is 
released, the action of a strong spring throwing the 
hammer at its extremity vigorously down upon a flexi- 
metre. The hammer works in a bell-shaped receiving- 
chamber, and the impulse thus imparted forces the air 
into sonorous undulations, which, after deflection along 
the walls of the chamber, are propagated without dis- 
persion to the ears of the listener by means of binaural 
tubes modelled after those of the Camman stethoscope. 
Dr. Robert Abbe, read a paper on 

SPINAL SURGERY: A REPORT OF EIGHT CASES. 

These cases, he said, had all been subjected to pro- 
longed medical treatment, and when referred to him 
were in almost a hopeless condition. Almost as many 
more cases had been refused operation ; but these 
seemed either to offer hope of relief based on experi- 
ence, or to give legitimate opportunity for novel 
operative methods based on sound physiological princi- 
ple. The spinal cord had been regarded as more in- 
accessible to the surgeon than the brain, and it was 
from the ranks of the doomed cases of paralysis of 
the lower half of the body, and some other spinal 
troubles that an effort was being made to call out 
more cases which, heretofore neglected, might yield 
good results. 

Having referred to the articles published by White, 
Winslow, Bennett, Horsley, MacEwen, Thorburn and 
others, he said it was evident that some cases of im- 
provement had been reported prematurely. The need 
of reporting carefully all cases where operation was 
done had Ud him to present his eight cases. These 
might be divided into four groups : three cases of 
paraplegia from fracture, one of early curetting of a 
vertebra for Pott's disease, two of tumors of the 



64 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 17, 1890 



vertebral canal with paraplegia, and two of intra- 
dural section of some of the posterior roots of the 
brachial plexus for neuralgia. 

Case I. Fracture of the spine between the elev- 
enth and twelfth dorsal vertebra? : complete para- 
plegia and anasthesia. Operation eleven months after- 
ward; breaking up iutra-dural adhesions; suture of 
dura ; primary union. No relief of paralysis up to 
one year afterward. 

The patient was a merchant twenty-seven years of 
age, who fell from a platform twenty-one feet high 
May 19, 1888. He was unconscious for three hours, 
and was completely paralyzed, and insensitive below 
the waist when he recovered. After three months he 
resorted to a wheel-chair, and attended to business. 
In April, 1889, he was brought from Texas, where he 
resided, to Dr. L. A. Sayre, who referred him to Dr. 
Abbe. The operation was performed April 12th. The 
back was shampooed the evening before, and a damp, 
sublimate dressing kept applied until the moment of 
operation. The patient having been laid prone, but 
with one shoulder raised by a sand pillow, a free in- 
cision was made parallel with the spines and half 
an inch to one side, cutting the longissimi attachments 
from one side only, and being carried clean down to 
the laminae at the second or third pass of the knife. 
To approach the fracture, the incision was made from 
the eighth dorsal to the first lumbar spine. The 
lamiuas were now cleared of muscles, which were 
drawn outward by retractors, and the ligament divided 
above the spine of the eighth and below the eleventh ; 
thus isolating a block of four spines, whose bases were 
then severed from their arches by stout cutting pliers. 
This manoeuvre at once allowed a retraction of the 
entire block of connected spines with their muscles 
still attached on one side, and the entire breadth of 
the spinal arch was thus exposed without sacrificing 
the overlying tissues. A pair of slightly curved ron- 
geurs was now applied to the lower edge of one lamina, 
and with incredible ease the entire breadth was quickly 
gnawed away. Three arches, the tenth, eleventh and 
twelfth, were thus treated, and the clean spinal cord 
laid bare for two and one-half inches. 

The twelfth dorsal vertebra was found to have been 
displaced backward, the fracture running through the 
articular facets, the pedicles and the lamina?, and the 
cord was compressed between the arch of the eleventh 
above and the upper lip of the body of the twelfth 
below ; while the intervertebral cartilage had been 
ruptured. Above the line of fracture, the cord pul- 
sated ; below, it did not. In half a minute after the 
cord was released from its flattened state (the bone- 
pressure area being only half an inch deep), the dura 
became rounded up as full as it was above or below. 
The wound now being irrigated and dried, the dura 
was slit up for two inches. Adhesions of various 
density were found within, attaching the meninges to 
the dura, and forming a complete circular dam, which 
shut off the upper from the lower part of the canal. 
Only an ounce of clear spinal fluid came out, as the 
spinal cord had purposely been inclined on the table 
so as to slope witii the head lower. The adhesions 
were broken up with very little force. The cord was 
normal in thickness above the involved part; then by 
a sloping, rather than abrupt change, it merged into a 
flattened cord for three-fourths of an inch, retaining 
its breadth, but less than half its thickness. The 
principal atrophy seemed to be in the posterior col- 



umns. Throughout this flattened portion the white 
fasciculi of the cord could be traced continuously ; so 
that there was no abrupt break in its continuity. 

The affected portion of the cord proved too exten- 
sive to render it possible to attempt to excise this and 
suture the fresh cut ends (a procedure never yet ac- 
complished) ; but to judge whether such a thing would 
ever be possible, Dr. Abbe tried to approximate the 
sound end on either side of the damaged part by trac- 
tion made with tenacula embedded in the meshes of 
the membranes at such points as would have been 
available for sutures. There being a slight latitude 
of motion of the cord vertically in the canal, he judged 
at this trial that he might have excised a scant quarter 
of an inch, and then approximated the ends by sutures 
that would not tear out. The damaged cord in this 
case was three times that length. 

No further repair being possible, the dura was sutured 
by fine cat-gut. Then the displaced spines were brought 
into line and sutured by heavy cat-gut to their neigh- 
bors above and below. The fascia investing the 
muscles next received two or three interrupted cat- 
gut sutures, with gaps for drainage, and finally the 
skin was drawn partly together by a few cat-gut 
sutures, not tied but left for use at the next dressing. 
No drainage-tube was applied, but a piece of protec- 
tive three inches wide was laid on the wound ; the 
skin edges being left a quarter-inch apart so as to 
allow drainage. The investing antiseptic dressing 
was covered by a plaster jacket covering only the 
back, like a turtle shell, and secured by an enveloping 
Canton flannel binder pinned in front. In forty -eight 
hours the dressing was changed. Drainage had been 
perfect, and the wound had healed except the skin, 
which the sutures already in place now brought to- 
gether when tied. A final dressing was then put on, and 
the wound healed primarily, leaving only a linear scar. 
The patient's condition has been watched since then 
and there has been no improvement in motion or sen- 
sation. 

Case II. Fracture of spine at the eleventh and 
twelfth dorsal vertebrae ; paraplegia. Operation after 
two and one-half years. 

This patient was also twenty-seven years of age. 
In October, 1886, he was thrown from his horse on 
his ranch in Montana and struck his back across a 
stick. Instantaneous and complete paraplegia re- 
sulted, with paralysis of the rectum and bladder. He 
lay for a day and a half where he fell without food or 
drink and exposed to sleet and snow. As soon as he 
was discovered he was taken to a farm-house, where, 
as a restorative, bottles of hot water so hot as to 
cause blistering were applied to his feet ; and the 
blister resulted in gangrene. After three weeks he 
was removed to his home in Connecticut, where it 
was found necessary to amputate both legs below the 
knee. His general health afterwards improved to 
such an extent that he was able to be placed in his 
carriage and drive about ; but a few months before he 
came under Dr. Abbe's care gangrene of the buttocks 
had resulted from his unwisely remaining in his buggy 
for about seven hours. His condition thus became 
desperate, and he was brought to New York in the 
hope that some method of operation might be devised 
for his improvement. 

He was examined by Dr. C. L. Dana, whose con- 
clusion was that the cord was absolutely severed at 
the last dorsal, but that below the second lumbar it 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



65 



must be in fairly healthy condition. The case seemed 
absolutely hopeless unless it was possible to innervate 
the lower segment of the cord by renewing its contact 
with the upper, or what seemed not impossible and 
perhaps worthy of trial, by carrying out a suggestion 
of Dr. Dana, in case the parts were not too much in- 
jured, to cut off a few of the lower dorsal roots long 
and the lumbar roots short, and suture them together, 
thus increasing the chance of getting: sensation. On 
April 18th, 1889, the same ' procedures were adopted 
as in the preceding case, and it was found that a 
massive and dense ebumated deposit of bone had 
formed at the site of the eleventh and twelfth dorsal 
and first lumbar lamina?. This was with dilliculty 
chiselled and cut away until the severed end of the 
spinal cord was exposed. Below this for one and one- 
half inches solid bone filled the vertebral canal, and 
beyond that the cord commenced again. Its end was 
found engaged in the bone so that spicule had grown 
into it ; and it was evident that repair by suturing was 
hopeless. The patient lived for only thirty hours 
after the operation, and during this time but four 
ounces of urine were secreted. 

Case III. Fracture of the twelfth dorsal vertebra; 
paraplegia. Operation. Recovery unimproved. 

The patient, who was of the same age as the other 
two, in alighting from a street car on January 1, 
1889, was struck in the small of the back by the rear 
platform of the car. He fell on his hands and knees, 
suffered acute pain in the back, and at once became 
paralyzed. He was operated upon on February 28, 
1889. The arch of the eleventh dorsal showed evi- 
dence of recent fracture, but there was no displace- 
ment and no pressure. When the dura was exposed, 
it appeared evenly full and round, and as far as its sur- 
face showed, nothing would have been suspected wrong 
within it. It was, however, slit for three and one- 
half inches, and from the lower part of the opening a 
little fluid escaped. At a point underneath the in- 
jured arch a circular dam of lymph was found, one- 
eighth of an inch wide, between the dura and the cord, 
entirely shutting off the upper from the lower part of 
the canal ; and from above this dam the arachnoid 
fluid flowed freely. The cord at this point showed 
evidence of having been completely crushed, the white 
substance endiug abruptly and beginning again some- 
thing over half an inch below. In the intermediate 
space the cord was represented by a pinkish gray sub- 
stance apparently consisting of only the meshes of the 
membranes. Just below the lymph dam a mass of 
largely distended veins occupied the surface of the 
cord, showing obstructed venous return. These en- 
tirely emptied themselves upward when the pressure 
was taken off and the lymph parted by the probe. 
The cord was entirely liberated from its adhesions, the 
dura sutured with fine cat-gut, and the wound closed. 
A temporary hyperesthesia of the paralyzed parts re- 
sulted from the operation, but there was never any 
voluntary motion, and the patient soon relapsed into 
his former condition. 

In commenting on these cases Dr. Abbe said that all 
operators upon cases of fracture paraplegia of any du- 
ration have thus far arrived at about the same con- 
clusion, namely, that the pressure of bone is of the 
most secondary importance, except the fracture in- 
volves only the arch, where it is driven in by a blow; 
inasmuch as the Violence which will produce instant 
paralysis has done so by a diastasis of the vertebra?, the 



cartilage being ruptured and the arches broken, which 
completely pulpifies the spinal medulla. The verte- 
bra: are very apt to immediately resume their usual 
relations. If, however, the fracture takes place at or 
below the last dorsal, where the medulla is replaced by 
the cauda equina, the crushing does not usually de- 
stroy the nerves; though long pressure would. In 
such case operation to correct it is always desirable. 
It still remains a problem, perhaps never to be solved, 
how to connect the lower segment of the cord with 
the upper, when there is a gap of half an inch, and 
whether this union would restore functional connec- 
tion with the brain, even though its reflex and in- 
dependent activity may be ever so good. 

Cask IV. Pott's disease taken early and treated as 
a tubercular caries in one of the joints. 

The case was narrated to show the ease with which 
the vertebral bodies, if carious, may be approached 
from behind. The patient was twenty years old. A 
probe inserted into a sinus resulting from a lumbar 
abscess passed upward to the last dorsal vertebra. 
An incision, guided by the probe, was made beside 
the twelfth dorsal. It was found that the transverse 
process of the vertebra was carious and it was cleared 
away with a bone curette, which was then worked 
into the body of the bone alongside the spinal dura, 
without injury to the latter. A large excavation of 
softened bone was removed (to the extent of about 
half of one vertebral body), and the curette then en- 
countered firm and apparently sound bone. The en- 
tire course of the pus track through the soft parts was 
curetted and douched with sublimate solution, and 
finally with solution of iodoform in ether. 

(To be continued.) 



decent Hiterature. 



Transactions of the American Surgical Association. 
Vol. VI. Edited by J. Ewing Meaks, M.D., Re- 
corder. Cloth, pp. 572. Illustrations and Plates. 
Philadelphia: P. Blakiston, Son & Co. 1888. 
This volume contains, besides a full report of the 
transactions of the 1888 meeting, a list of the officers 
and members, the president's address, and reprints in 
full of the papers read, with the subsequent discus- 
sions. The list is too extensive to enumerate separ- 
ately these interesting contributions, which are already 
well-known, from the pages of the principal medical 
journals, and subsequent publication of many as sep- 
arate monographs. They are all of worth, but those 
of Senn, Keen, Packard, Bull, Oay, Willard, Cheever 
and Park have apparently attracted the most atten- 
tion and interest. The work of the recorder and 
publisher has been excellently done, and this elegant 
volume, as has already been fittiugly said, is one "dis- 
tinctly a credit to American surgery." 

Suggestive Therapeutics : A Treatise on the Nature 
and Uses of Hypnotism. By H. Berniieim, M.D., 
Professor in the Faculty of Medicine at Nancy. 
Translated from the Second and Revised French 
Edition by Christian A. Herter, M.D. Octavo, 
pp. xvi, 420. New York and Loudon : G. P. Put- 
nam's Sons. 1889. 

Bernheim is to-day the acknowledged leader of the 
so-called Nancy school of hypnotism, and the volume 
before us is bis own presentation of the doctrines of 



66 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 17, 1890. 



that school. As is well-known, Bernheim is the dis- 
ciple of Liebault, the founder of the school, and he 
has taken strong ground against the views of hypno- 
tism presented by the school of La Salpetriere. Bern- 
heim's first chapter is devoted to the methods of hyp- 
notizing, and a classification of the stages of hypnosis. 
His method is strictly by verbal suggestion. To this, 
he claims, the majority of people are susceptible. In 
a single year only 27 out of 1,012 patients proved 
wholly refractory, and, he adds, " it is wrong to believe 
that the subjects influenced are all weak-nerved, weak- 
brained, hysterical, or women. Most of my observa- 
tions relate to men." He classifies the stages in two 
great divisions, according as memory is or is not pre- 
served on waking ; making nine classes, all told, from 
mild somnolency to states in which hypnotic and post- 
hypnotic hallucinations can be produced with amnesia 
on waking. This chapter is followed by four chapters 
giving careful details of the various physical and psy- 
chical conditions which may be present in the hypnotic 
state, a chapter against the doctrines of Charcot, an 
historical chapter, and two chapters devoted to ex- 
pounding his own theory of hypnotism. The second 
part deals with the therapeutic use of hypnotism, with 
the histories of 105 cases in which it was used 
with greater or less success. 

Bernheim maintains stoutly that the manifestations 
of hypnotism are due solely to suggestion, " the influ- 
ence exerted by an idea which has been suggested to 
and received by the mind." That the automatic con- 
dition thus produced is not abnormal is shown by the 
many automatic acts which we daily perform. In 
many of the cases, consciousness and will exist, in 
others, they are diminished or lost. There is, how- 
ever, " exaltation of the ideo-motor reflex excitability, 
which effects the unconscious transformation of the 
thought into movement, unknown to the will," or of 
the ideo-sensorial reflex, transforming thought into 
sensation or into a sensory image. " Sleep itself is 
born of a conscious or unconscious suggestion." Sug- 
gestions to be carried out after a long interval (sugges- 
tions a longue echeance) are due to latent memories 
(unconscious cerebration), such as those which enable 
us to awaken at a fixed time. The three stages of 
Charcot, lethargy, catalepsy and somnambulism are 
due solely to suggestion, and are not natural phases of 
the hypnotic state. 

The therapeutic action of hypnotic suggestion is, if 
we may accept Bernheim's results, something remark- 
able. Contracture in hemiplegia and hemianaesthesia 
from gross lesions of the brain, ulnar neuritis, pressure 
paralysis from fracture of the spine, myelitis, rheuma- 
tism, the pains of tabes, all forms of functional neuro- 
ses, gastritis, neuralgias, disorders of menstruation, all 
yield to suggestion ; while bad results are never seen. 
" When it is well managed, it does not produce the 
slightest harm." "Hypnotic sleep in itself is benefi- 
cial, and is free from harm as is natural sleep." The 
only risk is in producing post-hypnotic hallucinations. 

Such is the position that Bernheim takes in regard 
to hypnotism. It is certainly a question how far his 
views may be accepted. There is still much to be said 
in favor of the school of La Salpetriere; this, first of 
all, that it is composed of men trained in dealing with 
nervous phenomena, and, therefore, better able to ap- 
preciate them. The cases of grande hysterie are cer- 
tainly rare, but our knowledge of hysteria has received 
more light from the study of the pronounced phe- 



nomena in these cases than from the study of the much 
commoner mild hysterical symptoms. So of organic 
diseases, our knowledge must be based first on the 
study of pronounced and typical cases before we can 
appreciate the slighter and more transient phenomena. 
The same must be said of hypnotism ; the pronounced 
forms are to be seen only in the hysterical. The 
study of these cases will afford us knowledge of the 
type. Some of the milder symptoms, as Charcot has 
repeatedly admitted, can be obtained in many subjects ; 
but the work of Charcot has given us definite knowl- 
edge in the light of which these abortive cases can be 
studied. The study at La Salpetriere, as described by 
Richer, bears evidence of careful control and a scien- 
tific investigation ; it has, moreover, been in part cor- 
roborated by the independent and thorough work of 
two eminent Italian observers, Tamburini and Seppilli, 
whose work has received too little attention in this 
country. They have established that the phenomena 
of hypnotism are not due, as Bernheim claims, solely 
to suggestion, but that they can be produced by purely 
mechanical means. This view is strengthened by the 
fact that animals can be hypnotized ; here suggestion 
can hardly be called into account. 

It is, moreover, an untenable position, in the light 
of our present knowledge, to hold that the hypnotic 
sleep is practically the same as natural sleep. Physi- 
ological research shows some analogies, but also marked 
differences in the circulatory, respiratory and reflex 
phenomena. Sleep itself may be born of a suggestion, 
and Bernheim's explanations of the way suggestion 
works in producing normal sleep are very beautiful, 
but the unimaginative mind fails to discover the part 
suggestion plays in producing slumber in a six-hours- 
old baby or a week-old kitten. 

It certainly requires great credulity to accept the 
marvellous therapeutic benefits which Bernheim and 
some of his followers claim. The chances of self- 
deception on the part of the physician, and of conscious 
or unconscious deception on the part of the patient are 
great, and time alone can prove how many grains of 
salt are to be added to the prescription of suggestion. 
It renders us the more sceptical to find that the lead- 
ing neurologists who have studied hypnotism claim far 
less than do the few " hypnologists " of France who 
follow the professor of Nancy. The dangers, too, 
which Bernheim slights are certainly not to be ignored. 
Cases of grave, nervous disturbance following hypno- 
tism are not rare, and they rest on good authority; 
minor disturbances are probably still more common, 
and many observers have called attention to them. It 
is too early yet to pronounce definitely as to the fu- 
ture of hypnotism. It has added somewhat to our 
psychological knowledge. It has some therapeutic 
results to boast of, but whether it can give better, 
safer and more permanent results than our other 
measures of relief is still very doubtful. Except with 
a few enthusiasts, it seems already to be on the wane, 
and another decade will probably see it in its true 
place. 

To all interested in the study, however, Bernheim's 
work will appeal, for it is the gospel of the Nancy 
school, and as such, it demands the attention even of 
those who dissent from its doctrines. The translation 
has been well done, but it is curious to find a New 
York man following the error of the original in speak- 
ing of the late Dr. Beard as "of Boston." 

P. C. K. 



Vol. CXXI1I, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



67 



THE BOSTON 

jmeDtcal anD ^urgtcal journal* 



THURSDAY, JULY 17, 1890. 



A Journal of Medicine, Surgery, and Allied Sciences, published at 
Boston, Weekly, by the undersigned. 

Subscription Tekms : $5.00 per year, in advance, postage paid, 
for the United States, Canada and Mexico; $6.56 per year for all for- 
eign countries belonging to the I'ostal Union. 

All communications for the Editor, and all books for review, should 
be addressed to the Editor of the Boston Medical and Surgical Journal, 
283 Washington Street, Boston. 

All letters containing business communications, or referring to the 
publication , subscription, or advertising department of this Journal, 
should be addressed to the undersigned. 

Remittances should be made by money-order, draft or registered 
letter, payable to 

DAMRELL & UPHAM, 
283 Washington Street, Boston, Mass. 



RECENT VTEWS AS TO INFLAMMATION. 

This microbial doctriues of the present day have 
completely changed prevalent notions as to the nature 
and purport of inflammation. Formerly it was taught 
that inflammation was the result of a local irritant 
causing an excessive afflux of blood to the part with 
vascular paralysis and exudation ; this might be produced 
by a foreign body, as a thorn, a splinter of glass; it 
might be due to a poison in the blood, that is, some 
hypothetical fever poison, or materies morbi generated 
by cold. With the progress made in microbiology the 
past twenty or twenty-five years, the number of inflam- 
mations, clearly not of bacterial origin, has been greatly 
reduced ; some authorities, as Gerster, 1 affirm that 
microbes are the sine qua non of all inflammations. 

Even the ''idiopathic" inflammations such as acute 
pleuritis, meningitis, etc., would be explained by these 
writers as being of parasitic origin (tuberculous or 
rheumatic, etc., even rheumatism being regarded as an 
infectious disease). 

A popular hypothesis a few years ago was that in- 
flammation is an abnormal nutritive process, the nutri- 
tion of a part being exaggerated and perverted under 
the influence of an irritant. This was afterwards 
modified or supplemented by the theory of alteration 
of the blood-vessels, this favoring stagnation, diapede- 
sis, and exudation. Still later experimental investiga- 
tions have greatly lessened the importance of the role 
to be attributed to ordinary irritants. The classic 
" thorn in the flesh," if perfectly aseptic, is rather 
harmful by interfering with the function of the part 
and by pressure on nerves, than by exciting inflamma- 
tion or suppuration, which it does not do if all germs 
are rigidly excluded. Instances are cited 2 where foreign 
bodies, as well disinfected steel nails, the point of an 
aseptic knife-blade, a piece of glass perfectly clean, 
etc., have been imbedded in the tissues for weeks with- 
out causing any inflammation, or any great inconven- 
ience. Even dead organic substances taken from a 

1 Aseptic and Antiseptic Surgery, 1888. 

2 See Gerster, loc cit. 



freshly killed animal (blood, bits of muscle, tendon or 
bone) have been introduced into the abdominal cavity 
of animals under strict antiseptic precautions. "The 
animals being killed, it was found that blood was ab- 
sorbed outright; that muscle, liver, tendon and bone 
were incapsulated ; and that their structure was grad- 
ually invaded by granulation tissues, disintegration and 
final absorption following after a while, proportionate 
to the density of the implanted bodies." 

The author from whom we have quoted alludes to a 
remarkable experiment of Tillman performed on a 
rabbit, in the abdomen of which an entire rabbit's kid- 
ney was deposited without causing any harm whatever. 
After forty-seven days the implanted kidney was sought 
for in vain, as it had disappeared by absorption. It is 
quite certain that if in these cases the ordinary aseptic 
measures had been omitted, septic purulent peritonitis 
would have followed. 

With regard to chemical irritants, while there has 
not been uuiformity of results among experimenters, 
careful and painstaking workers, like Klemperer and 
Scheuerleu, have found that when substances such as 
croton oil, turpentine and bits of glass, rendered per- 
fectly aseptic, are antiseptically introduced under the 
skin of animals no suppuration has ever followed. 
" Small quantities caused some exudation of plasma, 
and then were absorbed outright." The fragments of 
glass " were found imbedded in a film of new formed 
connective tissue." Large quantities of croton oil, 
" caused a coagulation necrosis of a limited mass of 
tissue which was found dense, bloodless, and of a yel- 
low color." These nodes of necrosed tissue were grad- 
ually absorbed, " suppuration never following the ex- 
periment." 

As for the nature of inflammation, this is explained 
as follows — and here again we cannot do better than 
follow Gerster's lucid statement : 8 

"An injury of some kind has devitalized the tissues 
of a certain region, and these become a favorable pab- 
ulum for micrococci. The living tissues around still 
offer a decided resistance to the invasion of the microbe. 
Bacteria cannot thrive on the products of decomposi- 
tion ; they need for their sustenance dead, but unde- 
composed albuminoid subslauces. As soon as the 
supply of dead animal tissue is exhausted the micro- 
organisms starve and perish, 4 while the spores are left 
behind, dormant. We will suppose the injury, result- 
ing in the inflammation, to have been a wound ; this 
has destroyed the vitality of those cells that lie in the 
direct path of the cutting implement. The blood and 
lymph exuded from the vessels coagulate and also 
represent dead matter. 

" If a number of active micrococci are implanted 
into the bottom of the wound, they will at once multi- 
ply, using the blood-clot and its extenskns into the 
blood-vessels, together with the adjacent dead or de- 
vitalized tissues, as welcome soil for their development. 
This fermentative decomposition produces from the 
very beginning certain poisonous alkaloids, ptomaines, 

s Loc cit., p. 175. 

* We do not understand the author of " Aseptic and Antiseptic 
Surgery " to advocate the extreme view that all inflammations are 
necessarily microbic ; he certainly, however, teaches that all exter- 
nal inflammations are so. 



68 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 17, 1890. 



that are very diffusible. These have a toxic influence 
on the adjacent vaso-motor nerves, causing their para- 
lytic dilatation ; hence the active hyperemia, the rubor. 

" The blood, passing through the adjacent arterioles 
and capillaries seems also to become altered ; the red 
corpuscles become packed and finally stagnate in the 
smaller vessels. The walls of these vessels, including 
the veins, lose their impermeability, and there is emi- 
gration of the leucocytes and even of the red corpuscles 
into the surrounding tissues ; hence the swelling, tur- 
gor. 

" Chiefly as a consequence of the increased blood- 
supply, a marked increase of the local temperature is 
observed — color. Direct pressure caused by the dense 
infiltration, and the actual destruction of the nerve 
tissue, perhaps also, in some measure, the immediate 
influence of the ptomaines on the sensory nerve fila- 
ments of the part, give rise to pain, the dolor. 

" Stagnation and dense infiltration finally produce a 
very high degree of tension, leading to compression of 
large afferent vessels. The infiltrated portions, de- 
vitalized by suppression of the normal circulation 
readily succumb to the inroads of the millions of micro- 
organisms, and actual necrosis rapidly follows. The 
last stage of textural destruction is the final liquefaction 
of the tissues and infiltrating leucocytes, aided by the 
exudation of large quantities of lymph serum from the 
adjacent unobstructed blood-vessels, and thus we have 
the formation of an abscess, or a cavity filled with 
lymph serum, dead leucocytes (pus-cells) and shreds of 
necrosed tissue. 

" The veins also participate in the disturbance, and 
coagulation of their contents — thrombosis — takes 
place, and adds to the existing stagnation." 

In accordance with the explanation above given, 
any considerable extension of the septic process and 
absorption of the ptomaines into the general circula- 
tion produces those formidable accidents known as 
septic fever and pycemia. 

Such, in brief, is the latest teaching — by no means 
yet accepted by all pathologists — according to which 
the only phlogogenic irritant and pus-generator is the 
baneful microbe. 

COATS OR SHIRT-SLEEVES? 

To what extent the minimizing of raiment shall be 
carried during the summer months by those who are 
" off duty," and in the security of their own domiciles, 
will depend, of course, enti ely on the fancy of each 
individual thus fortunately situated. But upon those 
who, in a business or a social way, mingle with their 
kind, obvious limitations are imposed. The most su- 
perficial observation will show that the prevalent 
methods of hot-weather dress have improved in rea- 
sonableness of late years, with the increasing develop- 
ment of, various forms of " outing." Some very un- 
necessary comment was caused a year or two ago, dur- 
ing the hot weather, by the fact that certain United 
States senators appeared in their seats clad in flannel 
shirts. This summer a prominent Massachusetts con- 
gressman did not hesitate to wear in the House the 
8a8h-and-no-waistcoat garb which was comfortable and 
appropriate to the street. Yet another Massachusetts 



member has gone so far, in the course of a debate in the 
House, as to take off his coat altogether. It is said that 
the Speaker, whose ideas of prerogative have never 
been considered to lack virility, has, perhaps from his 
own stalwart person being wilted by the vertical rays 
of a Washington suu, so far yielded from his ordina- 
rily uncompromising attitude as to intimate mildly that 
he hoped the members who contemplated taking part 
in debate would, at least, keep their trousers on. 

And now the Memphis Cotton Exchange has been 
aggravating its already high temperature by a heated 
discussion as to whether the members of that board 
shall be allowed to do business in their shirt-sleeves. 
A strong conservative sentiment has developed, which 
seems likely to carry the day. 

Sociology should have its word on this subject as 
well as climatology. A coat is a coat, for purposes of 
civilization ; and when it can be as easily constructed 
of seersucker or pongee as of broadcloth, there seems 
little excuse for a gentleman's letting go of it alto- 
gether in public. If the National Congress and the 
Memphis Cotton Exchange do not stand firm on these 
points, the infection may spread, for aught we know, 
till it invades the pulpit and the Supreme Bench of 
the United States. 



MEDICAL NOTES. 

— The President last week transmitted to Congress 
a communication from Secretary Blaine announcing 
the action of the International American Conference 
regarding the better protection of the public against 
contagious diseases. Secretary Blaine in his letter 
says : 

" The sanitary officers of the Gulf cities of the United 
States have hitherto found great difficulty in protecting 
the public health against contagious diseases brought 
by shipping from South America, Central America, 
Mexico and West Indian ports, without restricting the 
freedom of commerce. At certain seasons of the year 
the quarantine regulations, which they have been com- 
pelled to adopt, have often placed an absolute embargo 
upon communication with the tropical countries where 
such diseases originate. The same difficulties have 
been experienced in a like measure by the neighboring 
nations, and the attention of sanitary specialists, both 
in Europe and America, has been for years engaged in 
the task of devising some remedy. 

" International sanitary conventions were held at Rio 
de Janeiro in 1887, and at Lima, Peru, in 1889, and 
were composed of eminent scientists who gave the sub- 
ject the closest investigation. At both these conven- 
tions regulations were framed for the protection of 
shipping and of ports exposed to infections, which 
agree in all their essential provisions. Those of the 
convention of Rio de Janeiro were adopted by Brazil, 
Paraguay, Uruguay and the Argentine Republic, and 
are now enforced in the ports of those nations. The 
recommendations of the Conference have not been 
carried into effect. Colombia, Venezuela, and the 



Vol. CXXIII, No. .!.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



69 



nations of Central and North America were not repre- 
sented at either convention, but they are equally inter- 
ested in securing the results desired, and the Interna- 
tional American Conference recommends the acceptance 
and enforcement by them of the regulations of the Rio 
de Janeiro Convention, or those adopted at Lima, as 
the hest systems that have yet been devised." 

— The Alvarenga prize of the College of Physi- 
cians of Philadelphia, consisting of one year's income 
of the bequest of the late Sefior Alvarenga, of Lisbon, 
has been awarded to Dr. R. W. Philip, of the Victoria 
Dispensary for Consumption and Diseases of the 
Chest, Edinburgh, for his essay on " Pulmonary Tu- 
berculosis," which will be published by the College. 

— It is said that the summer practice of Philadel- 
phia and New York physicians at watering places on 
the New Jersey coast is seriously interfered with by 
the new medical law which went into effect in New 
Jersey, July 4th. By this statute every physician 
seeking to practise within the State's limits after its 
passage, must submit to a formal examination by State 
officers. Exempted from the provisions of the law 
were " commissioned surgeons of the United States 
army, navy or marine hospital service, or regularly 
licensed physicians or surgeons in actual consultation 
from other States or Territories, or regularly licensed 
physicians or surgeons actually called from other 
States or Territories to attend cases in this State." 

Physicians called in consultation or those summoned 
to attend a special case were thus relieved of the 
necessity to pass an examination, but not so with the 
scores of doctors of Philadelphia and other cities who 
yearly settle at the seashore for the summer, and take 
up regular practice. The latter must be examined. 
A very few were forehanded enough to register under 
the old law before the new went into effect, and so 
become practically New Jersey physicians, on going 
through the necessary formula just in time. It is now 
found that out of over 2,000 practising physicians in 
Philadelphia, many of whom practise in New Jersey 
during the summer time at least, only 150 at the most 
have registered in New Jersey. 

— Another member of the British Peerage, the 
daughter of the Duke of Sutherland, has gone in for 
a course of training in nursing, having enrolled herself 
for that purpose in one of the London hospitals. 

— Druggist. — "I don't see why we should be ex- 
pected to sell postage stamps. They're not in our 
line." 

Brown. — " Of course they're not. When you run 
out of them you can't give anything else as a substi- 
tute." — Lippincott's Magazine. 

— Investigations recently made appear to show, as 
reported by a lay contemporary, that the lead-miner 
does not really suffer in health more than any other 
worker under ground, as the ore is not in a condition 
to - be absorbed by the body, but that lead-smelters 
and all engaged in the manufacture of lead, particu- 



larly white lead, run a very great risk of being con- 
taminated sooner or later. It also appears that at 
Tyne-sido, the chief centre of the English lead trade, 
there is one type of ailment which is rarely seen else- 
where, attacking those who have been engaged in the 
work only a few months, or even weeks — a fatal 
disease, the principal victims being girls of from 
seventeen to twenty-three years of age. They rapidly 
display symptoms of this form of toxemia in the way 
of severe headache, followed by colic, blindness, and, 
unless they speedily leave work for a considerable 
period of time and undergo most careful treatment, 
the fatal result is rapidly ushered in, usually with 
epileptiform convulsions and coma. It is remarkable, 
however, that but little trace of lead is found in their 
bodies after death, perhaps not more than a few grains 
in the internal organs after they have been subjected 
to the most complete and exhaustive examination. 

NEW ENGLAND. 

— The executors of the will of the late Dr. T. J. 
W. Pray of Dover, N. H., have recently paid a legacy 
of $1,000 in his will to Dr. L. G. Hill and others as 
trustees of the New Hampshire Medical Society. 

NEW YORK. 

— Mr. Cornelius Vanderbilt, in conjunction with 
his mother, Mrs. Wm. H. Vanderbilt, has given 
$250,000 for the erection and maintenance of a build- 
ing on East Forty-second Street, to be known as St. 
Bartholomew's Mission, which is designed for the 
health and comfort, as well as the morals, of the ten- 
ement population in the neighborhood. It will be 
constructed of white brick with dark red terra-cotta 
trimmings, and will be six stories high with a depth 
of one hundred feet and width of seventy-five feet. 
In the basement there will be a large swimming bath 
for the use, at different hours, of both sexes, with a 
heating apparatus for cold weather. On this floor will 
also be a kitchen and dining-room and a work-room for 
the temporary employment of people out of work. 
The main floor will be occupied by the chapel and a 
large hall for mission services, which will be two 
stories in height. The third floor will be devoted 
to rooms for the Sunday school and for mother's 
meetings and sewing classes ; and the fourth to a 
library, reading-room, boys' club and assembly and 
class rooms. The fifth floor will be fitted upas a fully 
equipped gymnasium, to be open at different hours to 
both men and women, and on the upper floor will be the 
offices and living rooms of those engaged in the ad- 
ministration of the establishment. The whole is to 
be under the direction of the rector of St. Bartholo- 
mew's church. 

— The city's mortuary reports are showing the 
effect of the recent hot weather. During the week 
ending July 5th, 1,010 deaths were recorded, an in- 
crease of 135 over the previous week, and showing a 
death-rate of 32.29 in an estimated population of 



70 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 17, 1890. 



1,631,848. Of these, 326 were from diarrboeal dis- 
eases in infants and young children. In order to 
prevent as far as possible the excessive mortality 
liable to occur among the children of the tenement- 
house population during the hot weather the usual 
summer corps of extra physicians has been appointed 
by the Board of Health, and they have been hard at 
work in house to house visitation since the first of 
July. The St. John's Guild Floating Hospital excur- 
sions and other charitable agencies for removing poor 
children temporarily to the country and seaside also 
have a favorable effect in keeping down the number 
of deaths. 

— In a case in Brooklyn in which a patient was 
supposed to have died of an over-dose of hyoscyamine, 
in consequence of a druggist's mistake, the under- 
taker in charge of the body in some way was allowed 
to use an embalming process (which effectually de- 
stroyed all traces of the poison, if such there were), 
before the coroner made his post mortem examination. 
Consequently the case against the clerk who put up 
the prescription, who had been held in $2,000 bail, 
will probably fall to the ground. 

— A druggist's clerk on Centre Street recently 
made the blunder of giving oxalic acid to a man who 
asked for five cents' worth of Epsom salt ; but fortu- 
nately it was discovered that a mistake had been 
made in time to save the patient's life. He was 
promptly taken to the Chambers Street Hospital, and 
the use of the stomach pump was followed by a satis- 
factory result. 

— All preparations have been made for opening the 
new Croton aqueduct on the loth of July. The tun- 
nel of the aqueduct is 29.63 miles long, and its esti- 
mated capacity is 318,000,000 gallons for twenty-four 
hours. The pipe line from 135th Street to the reser- 
voirs in Central Park has a capacity of 250,000,000 
gallons for twenty-four hours, and is 2.37 miles long. 

— The State Commission in Lunacy, as a result of 
a series of visitations recently made to the State asy- 
lums, has urged the adoption of very strict regulations 
for the prevention of fire in these institutions. 

— For the third time Kemmler has been sentenced 
to death, and the execution is now fixed for the week 
beginning August 4th, at Auburn Prison. 

— The Board of Health has been making an inves- 
tigation of the pipes of the Steam Heating Company 
in the lower part of the city, and in consequence of 
the results brought to light, has passed a resolution to 
effect that in its opinion the heat from the steam 
mains that are laid in close proximity to the gas 
mains, to the Croton water mains and to the sewers 
and vaults, creates new and dangerous emergencies 
and greatly increases the risk to the public health 
from the streets and street openings, sewers and vaults 
in the part of the city examined; and that the 
extreme heat coming from these mains is a menace to 
the public health, and its effect on the basements of 
many buildings bituated along the line of these steam 



mains is productive of conditions dangerous and det- 
rimental to life and health. In accordance with this 
resolution the Board, by virtue of the authority legally 
vested in it, has issued orders declaring the steam 
mains at certain points to be a public nuisance, and 
requiring that they no longer be used. 

The investigation showed that the high temperature 
noted was to be ascribed in part to direct radiation 
from the steam mains and in part to the escape of 
steam from leaks in the mains. In some places the 
water service was affected ; the water being delivered 
at a very high temperature. The report of the inspec- 
tors who made the examination goes on to say : " The 
numerous explosions which have occurred, especially 
in the lower districts of the city, are chiefly due to 
leakage of gas from the gas mains, as would appear 
from the fact that the leakage is greater from the 
mains laid in streets in which there are steam mains 
than elsewhere. . . . The heat of the steam mains is 
intermittent and causes contraction and expansion of 
the gas mains, thereby loosening the joints and caus- 
ing them to leak. . . . The gas escapes into sewers 
and subway manholes, forming an explosive mixture 
with the air. It becomes ignited and explosion 
ensues." 



STANLEY'S ESTIMATE OF HIS DOCTOR. 

In Stanley's book " In Darkest Africa " he speaks 
repeatedly with the greatest esteem of the medical 
officer of the expedition, Surgeon Parke. We insert 
one such paragraph: 

" This expedition possesses the rarest doctor in the 
world. No country in Europe can produce his equal 
in my opinion. There may be many more learned 
perhaps, more skilful, older, or younger, as the case 
may be, but the best of them have something to learu 
from our doctor. He is such a combination of sweet- 
ness aud simplicity ; so unostentatious, so genuinely 
unobtrusive. We are all bound to him with cords of 
love. We have seen him do so much out of pure love 
for his ' cases,' that human nature becomes ennobled 
by this gem. He is tenderness itself. He has saved 
many lives by his devoted nursing. We see him each 
day at 8 A. m. and 5 p. m., with his selectest circle of 
'sick' around him. None with tender stomach dare 
approach it. He sits in the centre as though it was a 
rare perfume. The sloughing ulcers are exposed to 
view, some fearful to behold, and presenting a specta- 
cle of horror. The doctor smiles and sweetly sniffs 
the tainted air, handles the swollen limbs, cleanses 
them from impurity, pours the soothing lotion, cheers 
the sufferers, binds up the painful wounds, and sends 
the patient away with a hopeful and grateful look. 
May the kindly angels record this nobleness aud oblit- 
erate all else ! I greatly honor what is divine in man. 
This gift of gentleness and exquisite sensibility appeals 
to the dullest. At Abu-Klea our doctor was great; 
the wounded had cause to bless him ; on the green 
sward of Kavalli, daily ministering to these suffering 
blacks, unknowing and unheeding whether any re- 
garded him, our doctor was greater still." 



Vol. CXXIII, No. 3.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



71 



MEDICAL INSPECTION OF IMMIGRANTS BY 
CONSULAR PHYSICIANS. 

Pricss dispatches state that the United .States Marine 
Hospital service lias decided to establish physicians at 
every port in Europe from which immigrants embark 
to this country, in connection with the United States 
Marine-Hospital service. 

The physicians will, in every case, work under the 
supervision of the United States Consul at the port 
where they are stationed. It will be the duty of these 
doctors to examine immigrants intending to sail for this 
port, and to prevent the embarkation of the great army 
of the lame, the halt and the blind people, who for 
years have been pouring into this country, only to fill 
up the county and State pauper institutions. 

Particular attention will be given to rejecting peo- 
ple suffering from contagious diseases and all com- 
plaints of a scrofulous nature. 



The plan proposed has been successfully carried out 
in connection with the Marine-Hospital service in West 
Indian and South American ports, and the effect of 
this protection to the United States in the exclusion 
of contagious diseases is considered inestimable by the 
members of the service. Thus, while yellow fever is 
raging at Santos and Rio -Janeiro, Brazil, there is very 
little danger of its getting into New York, even in the 
summer season. 

In connection with this work, the European consuls 
are expected to also make examinations particularly 
with regard to criminal cases and those who claim to 
be citizens of this country. If the candidate proves 
to be actually a citizen, the consul will issue to him a 
certificate. 

It is understood that women about to become 
mothers will also be included in the class to be kept 
from embarking. 



REPORTED MORTALITY FOR THE WEEK ENDING JULY 5, 1890. 



Cities. 



New York 

Chicago . . 
Philadelphia 

Brooklyn . . 

St. Louis . . 
Baltimore 

Boston . . . 
Cincinnati 
New Orleans 

Pittsburgh . 

Milwaukee . 

Washington . 

Nashville . . 

Charleston . 

Portland . . 
Worcester 

Lowell . . . 

Cambridge . 

Fall River . 

Lynn . . 

Springfield . 
Lawrence 
New Bedford 

Holyoke . . 

Somerville . 

Brockton . . 

Salem . . . 

Chelsea . . 

Haverhill . . 

Taunton . . 

Gloucester . 

Newton . . 

Maiden . . 

Waltham . . 
Fitchburg 
Attleborough 

Pittsfield . . 

Quincy . . 
Newburyport 

Woburn . . 



Estimated 
Population 
for 1890. 



,622,237 
,100,000 
,061,277 
852,167 
550,000 
500,343 
418,110 
325,000 
260,000 
210,000 
240,000 
230,000 
68,513 
60,145 
42,000 
81,622 
73,370 
67,026 
64,092 
55,200 
41,520 
41,058 
38,218 
37,867 
35,516 
30,811 
29,242 
28,781 
27,124 
25,544 
24,904 
22,011 
20,615 
17,998 
17,304 
15,994 
15,762 
14,114 
13,915 
13,089 



Reported 
Deaths in 
each. 


Deaths 
under Five 
Years. 


Percentage of Deaths from 


Infectious 

I J j qpq qaa 
I ' 1 otdoco . 


Consump- 


Diphtheria 
and Croup. 


Diarrhceal 

DiSG3.S6S. 


Typhoid 


1010 


663 


42.57 


7.29 


1.89 


32.31 


.27 


623 
552 
312 
242 
146 


336 
373 
164 
131 

52 


29.92 
42.06 
25.28 
37.72 
9.66 


10.72 
4.86 

20.80 
9.43 

15.87 


1.44 
4.86 
.96 
1.64 
4.83 


25.14 
34.56 
22.72 
30.34 
.69 


2.08 
.36 
1.28 
2.05 
.69 


185 


66 


22.14 


11.88 


.54 


15.66 


1.08 


130 
33 
49 


70 
17 
20 


32.34 
27.27 
18.36 


7.69 
6.06 
12.16 


1.54 


23.07 
24.24 
14.28 


5.39 
2.04 


19 
40 
16 
19 


7 
22 

7 
13 


21.04 
42.50 
18.75 
57.86 


16.78 
5.00 
37.50 
10.52 


2.50 
5.26 


15.78 
30.00 
6.25 
47.34 


7.50 


21 

29 
13 


4 
6 
14 
4 


28.56 
24.15 
15.38 


14.28 
20.70 
7.69 


19.04 


4.76 
17.25 
7.69 


3.45 
7.69 


18 


3 


11.11 


5.55 


5.55 


5.55 




6 
11 

5 
6 
5 


2 
3 

1 

2 


9.09 
40.00 
16.66 


20.00 

33.33 




9.09 
20.00 


20.00 


8 
1 

5 


1 


3 




40.00 








3 
4 
5 


2 
2 
1 


33.33 
50.00 


20.00 


33.33 
25.00 





















Deaths reported 3,406 ; under five years of age 1,990 : principal 
infectious diseases (small-pox, measles, diphtheria and croup, 
diarrhceal diseases, whooping-cough, erysipelas and fevers) 1,203, 
diarrhceal diseases 965, diphtheria and croup 84, typhoid fever 
44, measles 28, whooping-cough 27, scarlet fever 21, malarial 
fevers 19, cerebro-spinal meningitis 11, erysipelas 4. 

From measles, New York 23, Baltimore 3, Brooklyn and Boston 
1 each. From whooping-cough, New York 10, Philadelphia 4, 
Brooklyn, Boston and Cambridge 2 each, St. Louis, Baltimore, 
Washington, Charleston, Lowell, Lawrence and Quincy 1 each. 
From scarlet fever, New York 9, Brooklyn 4, Baltimore 3, Phil- 
adelphia, Boston, Washington, Worcester and Springfield 1 
each. From malarial fever, New Orleans 9, New York 5, Brook- 
lyn 2, Philadelphia, Baltimore and Nashville 1 each. From 



cerebro-spinal meningitis, New York 4, Brooklyn, Baltimore, 
Boston, Washington, Fall River, Lynn and Gloucester 1 each. 
From erysipelas, New York 3, Brooklyn 1. 

In the twenty-eight greater towns of England and Wales with 
an estimated population of 9,715,559, for the week ending June 
21th, the death-rate was 17.9: deaths reported 3,334: acute 
diseases of the respiratory organs (London) 215, measles 172, 
whooping-cough 99, scarlet fever 65, diarrhoea 57, fever 35, 
diphtheria 32, small-pox (Derby and Hull 1 each) 2. 

The death-rates ranged from 11.8 in Brighton to 29.0 in Man- 
chester: Birmingham 18.6, Bolton 23.9, Hull 15.9, Leeds 14.9, 
Leicester 14.9, Liverpool 21.9, London 16.4, Nottingham 12.6, 
Sheffield 24.4. 

In Edinburgh 16.9, Glasgow 25.9, Dublin 20.8. 



72 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 17, 1890. 



The meteorological record for the week ending July 5, in Boston, was as follows, according to observations furnished by 
Sergeant J. W. Smith, of the United States Signal Corps: — 



Week ending 


Barom- 
eter. 


Thermometer. 


Relative 
Humidity. 


Direction of 
Wind. 


Velocity of 
Wind. 


State of 
Weather.* 


Rainfall. 


Saturday, 


■ 

03 


i 


a 


a 








a 






















3 


s 


July 5, 1890. 


CP 


B 
■ r , l 


3 

a 


3 

a 

'3 


S 

■4 




2 
h 


O 

B 


a 




a' 


a 




S 


a" 

4 






a 


bB 

jg« 
2 " 


+^ CO 
3 4> 

"•s 








a 




o 




o 




© 




© 


o 




o 


© 






o 




af 






'3 


B 


B 


o 




© 


"3 


© 




o 


o 




© 


© 






o 








O 


ft 






00 




00 


Q 


00 




OD 


00 




00 


00 






00 


fl 




SnnJuv 90 
•J UlJUctj , . . . £u 


29 89 


64.0 


73.0 


56.0 


58 




66 


62.0 


N.E. 




S.W. 


4 




14 


C. 






F. 






Monday, ..30 
Tuesday, . . 1 


29.91 


72.0 


86.0 


58.0 


65 




74 


70.0 


W. 




S.W. 


5 




12 


C. 






c. 






29.98 


70.0 


71.0 


67.0 


69 




81 


75.0 


N.E. 




E. 


8 




6 


c. 






0. 






Wednes. . . 2 


29.96 


70.0 


77.0 


63.0 


85 




86 


85.0 


S. 




s. 


4 




12 


o. 






o. 






Thursday,. 3 


29.82 


71.0 


77.0 


66.0 


83 




77 


80.0 


S. 




s. 


12 




15 


o. 






o. 




0.03 


Friday, 4 


29.79 


74.0 


80.0 


68.0 


82 




80 


81.0 


S. 




s. 


6 




10 


0. 






o. 




0.05 


Saturday,. 5 


29.96 


76.0 


83.0 


70.0 


57 




53 


55.0 


N.W. 




N.W. 


5 




5 


c. 






c. 




T. 


Mean for 
Week. 





























*0., cloudy ; C, clear ; F., fair ; G., fog ; H., hazy ; S., smoky ; R., rain ; T., threatening ; N., snow, t Indicates trace of rainfall. 



OFFICIAL LIST OF CHANGES IN THE STATIONS AND 
DUTIES OF OFFICERS SERVING IN THE MEDICAL DE- 
PARTMENT, U. S. ARMY, FROM JULY 4, 1890, TO JULY 
11, 1890. 

Captain John de B. W. Gardiner, assistant surgeon, having 
been found incapacitated for active service by an army retiring 
board, and having complied with paragraph 12, Special Orders 
35, June 10, 1890, from this office, is, by direction of the acting 
Secretary of War, granted leave of absence until further orders 
on account of disability. Par. 3, S. O. 153, A. G. 0., July 2, 
1890, Washington, D. C. 

By direction of the Secretary of War, the leave of absence, on 
surgeon's certificate, granted Captain Marcus E. Taylor, as- 
sistant surgeon in Special Orders 45, June 13, 1890, division of 
the Pacific, is extended five months on surgeon's certificate of 
disability, with permission to go beyond sea. Par. 6, S. O. 159, 
A. G. O., July 10, 1890. 

Captain Samuel Q. Robinson, assistant surgeon, is relieved 
from temporary duty at the United States Military Academy, 
West Point, N. Y., to take effect upon the arrival there of Cap- 
tain W. Fitzhugh Carter, assistant surgeon, and will report in 
person to the commanding officer, Fort Du Chesne, Utah Ty., 
for duty, relieving Captain Curtis E. Price, assistant surgeon. 
Captain Price, on being relieved by Captain Robinson, will 
proceed to Fort Wardsworth, New York Harbor, and report in 
person to the commanding officer of that post for duty, relieving 
Captain Robert B. Benham, assistant surgeon. Captain Ben- 
ham, on being thus relieved from temporary duty at Fort Wads- 
worth, will report in person, without delay, to the commanding 
officer, Fort Hamilton, New York Harbor, for duty. Par. 12, 
S. O. 153, A. G. O., July 2. 1890, Washington, D. C. 



OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS 
OF THE U. S. NAVY FOR THE WEEK ENDING JULY 
12, 1890. 

Rixey, P. II., surgeon, leave of absence granted for fifteen 
days. 

Ogden, F. N., assistant surgeon, promoted to be a passed 
assistant surgeon. 

White, S. Stuart, assistant surgeon, promoted to be a 
passed assistant surgeon. 

Atlee, L. W., assistant surgeon, granted three months' leave 
of absence. 

Woolverton, T., medical inspector, await orders to the U. 
S. S. " Philadelphia." 

Lovering, P. A., past assistant surgeon, await orders to the 
U. S. S. " Philadelphia." 

MrMiJRTKiE, D., medical inspector, granted leave of absence 
for thirty days. 



OBITUARY. WILLARD EVERETT SMITH, M.D., M.M.S.S. 

Dr. Willard Everett Smith died, at his home in Boston, July 
11th, after an eight days' illness from peritonitis. Dr. Smith 
was a graduate of the Harvard Medical School in 1882. lie first 
located for practice in Framinghani Centre, marrying his wife, 
a Miss Newell, there. A few years ago he removed to Boston, 
tie hud been a valued contributor to this JOURNAL, and had 
prepared useful reports to the Massachusetts Medical Society on 
the Distribution of Disease in this State. 



BOOKS AND PAMPHLETS RECEIVED. 

A Consideration of Sexual Neurasthenia. By Brausford Lewis, 
M.D., of St. Louis, Mo. Reprint. 1890. 

McGill University, Montreal. Annual Calendar and Faculty 
of Medicine. Fifty-Eighth Session 1890-91. 

Thirtieth Annual Announcement of the Bellevue Hospital 
Medical College, New York City, 1890-1891, with the List of 
Graduates for 1890. 

Illustrated Catalogue and Price List of Dr. Geo. H. Taylor's 
Remedial Apparatus. The Improved Movement Cure Institute, 
71 E. 59th Street, New York. 

Twenty-Third Annual Report of the Directors of the Massa- 
chusetts Infant Asylum, Presented to the Corporation at the 
Annual Meeting April 8, 1890. 

Twelfth Annual Report of the Connecticut State Board of 
Health, for the year ending November 30, 1889, with the Regis- 
tration Report for 1888, relating to Births, Marriages, Deaths 
and Divorces. 

Terminologia Medica Polyglotta, A Concise International 
Dictionary of Medical Terms. Compiled by Theodore Maxwell, 
M.D., B.Sc, Lond.: F.R.C.S., Edin. ; etc. London: J. & A. 
Churchill. 1890. 

The Use of Powdered Jequirity in Certain Affections of the 
Eye. By W. Cheatham, M.D , Lecturer on Diseases of the Eye, 
Ear, Throat and Nose, Medical Department, University of 
Louisville. Reprint. 1890. 

I. Operative Treatment of Hip-Disease. II. Rest and Fixa- 
tion in Joint-Disease. By De Forest Willard, M.D., Ph.D., 
Clinical Professor of Orthopaedic Surgery in the University of 
Pennsylvania, etc. Reprint. 1889. 

The Brooklyn Health Exhibition. Held under the auspices of 
the Local Committee of Arrangements of the American Public 
Health Association (at its Seventeenth Annual Session) at 
Brooklyn, N. Y., October 22 to November 30, 1889. 

Supra-Vaginal Hysterectomy. Hysteromyomectomy with 
Suspension of the Stump in the Lower Angle of the Abdominal 
Incision. By Howard A. Kelly, M.D., Gynecologist to the 
Johns Hopkins Hospital, Baltimore. Reprint. 1890" 

A Manual of Anatomy for Senior Students. By Edmund 
Owen, M.B., F.R.C.S., Surgeon to St. Mary's Hospital, London, 
etc., Co-Lecturer on Surgery in its Medical School. With 
numerous illustrations. London : Longmans, Green & Co. 1890. 

Lecons de The'rapeutique. Par Georges Hayem, Professeur 
de Therapentique et de Matiere Medicale a la Faculte de Mede- 
cine de Paris, Membre de l'Academie de Medecine. Deuxieme 
serie. Les Medications (Cours professe' a la Faculte de mede- 
cine de Paris pendant l'aiine'e 1888). Paris: G. Massou, Edi- 
teur. 1890. 

Reciprocal Responsibilities. An Address Delivered on the 
Part of the Faculty at the Forty -First Commencement Exercises 
of the Medical Department of Georgetown University, at 
Lincoln Hall, on May 5, 1890. By Swan M. Burnett, M.D., 
Ph D., Professor of Ophthalmology and Otology in the Uni- 
versity, etc. 

Annual of the Universal Medical Sciences. A Yearly Report 
of the Progress of the General Sanitary Sciences throughout the 
World. Edited by Chas. E. Sajous, M.D., and seventy-five 
associate editors, assisted by over two hundred corresponding 
editors, collaborators and correspondents. Illustrated with 
chromo-lithographs, engravings and maps. Vols. I, II, III, IV, 
V. Philadelphia, New York, Chicago, Atlanta and London : 
F. A. Davis. 1890. 



Vol. CXXIII, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



73 



ilcctutre. 



INFLUENZA IN MASSACHUSETTS. 1 

BY (iKOKOK B. BHATTUOKi M.D., OF BOSTON, 
BRISTOL COUNTY. 

I iiavk tabulated thirteen manufacturers' returns 
from Bristol County, covering about 7,000 employees. 
Of these three are from New Bedford, six from Fall 
River, three from Taunton — all in the southern half 
of the county — and one from Attleboro near the 
northern border. 

The earliest first case, December 14th, is reported 
from Attleboro' at the north, but two mills at Fall 
liiver report first cases December 15th ; the latest 
first cases are at Fall River and New Bedford — the 
southern extremity, but in close railroad communication 
with Boston — each January 6th ; the largest mill at 
New Bedford, however, reports its first case Decem- 
ber 31st, and the third mill January 1st. 

The three returns from Taunton agree substantially 
upon December 30th as the date of the first case. 
All the returns, except one from Fall River, which 
names the last week of December, agree practically 
upon the second week of January as the maximum 
week. 

The percentage of affected varies from 60% to 5%, 
the average being 29% ; the absence from work an 
average of five days. 

The superintendent of the Granite Cotton Mill at 
Fall River writes a letter of some interest under date 
of February 4th : 

" The influenza made its appearance among our 
people December 27th, the day after the great gale 
which swept over the Eastern States. December 
30th, when the temperature fell from 54° F. to 37° F., 
the number of victims increased rapidly, and reached 
a crisis a few days after January 1st, when there was 
another fall in temperature from 36° to 20°, followed 
by a cold wave, which those who dressed in holiday 
attire and engaged in New Year's festivities were not 
prepared to meet, and the number of victims con- 
tinued to increase until January 13th, when a large 
percentage returned to work, and since that the 
number of those off work has steadily decreased, and 
to-day there are only seven cases among 836 em- 
ployees. 

The treasurer of a cotton mill at Taunton, 1,200 
employees, sends very accurate figures, from which it 
appears that of 650 males, 221 were sick, an average 
of 4.73 days ; and of 550 females, 259 were sick, an 
average of 5.95 ; so that at this mill the females were 
sick in greater numbers and more seriously. 

Medical Returns. — I have tabulated seven medical 
returns from this county, all from the southern half 
of the county, except one from Attleboro'. The ear- 
liest first case is December 10th, from New Bedford; 
the latest first case, December 28th, from Fall River 
near by. The next earliest case is from Attleboro', 
at the northern part of the county, December 18th. 
All the returns, except one, which gives the first week 
in January, name the second week in January as the 
maximum week. 

The percentage of affected varies from 60% in 
Attleboro' to 10% in Fall River. Average 33%. 

1 Delivered before the Massachusetts Medical Society June 10, 
1890. Continued from page 52 of the Journal. 



Sex. — Three state that males were most affected, 
one females. 

Other Diseases. — Four returns state that pneumo- 
nia was most increased in frequency. 

Conclusions. — I think we may conclude from the 
two classes of returns in this county that influenza 
was at least a week later here than in Boston (Suffolk 
County) and that where males and females were 
equally withdrawn from out-door exposure the females 
suffered more. 

PLYMOUTH COUNTY. 

Only three factory returns received, all three from 
shoe shops in Brockton and its neighbor Cam pel lo, in 
the northwestern corner of the county. These re- 
turns cover nearly 1,000 employees. 

The answers to question 1 are January 1st, 2d and 
10th ; to question 2, the 3d of January, the second 
week and the third week ; that the climax was not 
reached any earlier in the shop where the first case 
occurred January 1st, than where it occurred January 
10th. The percentages of affected were 60%, 20%, 
and 40% ; and the days of absence from work 2, 7 
and 5. The sexes are returned as affected alike. 

Medical Returns. — There are four from Plymouth 
County. From Abington the answers to questions 1 
and 2 are December 5th and the week from Decem- 
ber 29th to January 4th ; from Brockton the answers 
to 1 and 2 are December 20th and second week in 
January ; to question 3 this return gives 50% of the 
population as attacked. From Middleboro', farther 
south, the first case is reported as occurring on the 
same day as at Brockton, and the climax as occurring 
the same week, but only 10% of the population was 
affected. 

From Rockland, the next township to Abington, 
the first case is set down for December 22d, eighteen 
days later than the first case at Abington ; the climax, 
however, was reached about the same time in the two 
towns; at Rockland only 6% is returned as attacked. 

Three of the four answer the male sex to question 
5 ; two specify pneumonia, and one pulmonary dis- 
eases as being increased. 

Obviously no definite conclusions can be drawn 
from the returns from this county. 

The case in Abington, December 4th, was probably 
antecedent to the true epidemic ; and the epidemic 
perhaps began a little later and culminated a little 
later than in Suffolk County. 

NORFOLK COUNTY. 

Five factory returns, one silk, one woollen, one cot- 
ton, one straw, cover from 1,500 to 2,000 employees. 
The earliest first case is December 1 6th, the latest 
December 28th ; in two returns the climax is reached 
the first week in January, in two the second week in 
January, in one the week January 4th to 11th. 

The silk factory reports 60% of affected aud of 
absentees an average of 5 days ; the straw factory 
50% of affected and 20% of absentees, an average 
of 3 days ; the woollen mill 15% of affected aud 10% 
of absentees, an average of 4 days; the cotton mill 
6% of affected and 3% of absentees, an average of 3 
days. The first case at the woollen mill in Dedham was 
December 16th, and the first case at the cotton mill 
at Readville in the next township was December 25th, 
but the period of greatest activity at each Was the first 
week in January. 



74 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 24, 1890. 



Medical Returns. — There are thirteen from Nor- 
folk County representing twelve different towns. 
West Medway, at the western border of the county, 
reports a first case as early as October 20th — evi- 
dently a sporadic case of catarrhal fever ; Hingharn 
near the coast, and just north of Abington, with its 
first case December 4th, reports its first case Novem- 
ber 15th ; 12 "distinct cases" are reported as occur- 
ring in Brookline November 17th — perhaps a local 
outbreak ; Stoughton, on the southern border of the 
county and contiguous to Brockton, with its first case 
December 20th, reports a first case November 20th ; 
Dedham's first case is returned for December ] 2th ; 
of two returns from Hyde Park, one gives the first 
case as December 7th, the other December 27th ; 
the Medical Examiner at Brookline gives the date of 
the first case there as December 15th ; the first case 
at Foxboro' is the latest — December 25th. East 
Weymouth gives December 21st; Braintree and Ran- 
dolph (next to Stoughton with its first case November 
20th) give December 20th. Eight towns return the 
first week in January or the week from December 
28th to January 4th, as the week of greatest prevalence. 
Two towns, West Medway with its first case October 
20th, and Hingharn with a first case November 15th, 
report the second week of January as the week of great- 
est prevalence, which indicates pretty well the character 
of the so-called first cases. The return from Hyde Park 
which dates the first case December 7th, puts the 
climax at the fourth week of December ; that from 
Quiucy which dates the first case December 1st, puts 
the climax the first week in January, the same week 
as those dating the first case December 20th. At 
Braintree and Wellesley Hills 75% of die population 
is said to have been attacked ; various percentages 
are given for the other towns between this and 20% 
for Hingharn and 15% for Brookline at the other end 
of the scale. The average is 51%. 

Sex. — Eight returns from as many different towns 
specify the male sex as having been most severely af- 
fected. The others make no return to this question, 
except one which states that the female population was 
the larger. 

Medical Returns. — Seven returns state that pneu- 
monia was increased, and three others that pulmonary 
diseases were increased. One return mentions capil- 
lary bronchitis in connection with pneumonia. 

SUFFOLK COUNTY, 

the next on the north, is really the City of Boston 
with Chelsea ; from the small towns of Revere and 
Winthrop, also within the county limits, there are no 
returns. 

There are seven returns from the large Boston dry 
goods stores. One places the first case as early as 
December 1st, but reports the same week of greatest 
prevalence (December 28th to January 4th) as an- 
other store which reports the latest first case of the 
seven, December 22d. Two date the first case De- 
cember 10th, one December 16th, one the 20th. 
Four give Christmas week as the climax, but this is 
partially explained by one return which says: "Our 
employees were lightly touched, and there were no 
more absences than usual at Christmas time which is 
always the cause of much fatigue." Two stores 
return 50% of employees as affected and 45% as 
absent in consequence; one returns 50% as affected 
but only 5% as absent — a singular discrepancy ; one, 



33% as affected and 25% absent; one, 10% affected 
and absent. The average duration of absence varied 
from 2 to 7 days. Two stores report the male sex as 
most seriously affected. 

There are returns from nine banks and Trust Com- 
panies. Among the personnel of two banks no case 
of influenza occurred. One dates the first case De- 
cember 10th, one December 13th, one December 16th, 
one December 17th, one December 20th and one the 
27th. The large banking house with 44 employees 
reporting its first case December 13th, gives the 
second week of December as the week of greatest 
prevalence; 60% were attacked and 45% were ab- 
sent an average of four days. If this is a correct 
statement, and there is every reason to accept it, it 
indicates that the epidemic exhibited an almost explo- 
sive character at this point. 

A Trust Company, with 26 officers and clerks, dat- 
ing its first case December 17th, gives the immediately 
following week as that of greatest prevalence. 

Two banks report 75% of affected with 25% and - 
20% of absentees; one, 50% with 33% absent; one, 
33% affected and absent; one, 25% affected and ab- 
sent. The average of absences varied from three to 
six days. 

At the Trust Company with 26 employees, three had 
a second attack incapacitating for work ; and " the 
oldest " of the staff are reported to have had immun- 
ity. 

These bank returns dealing with comparatively 
small numbers under immediate supervision, are prob- 
ably pretty reliable. They indicate that the influenza 
began as an epidemic in Boston about the middle of 
December and was on the wane by January 4th ; that 
at least 50% of the young and middle-aged male pop- 
ulation were attacked, and that about 25% were inca- 
pacitated for work for four or five days. 

The return of the Central Boston Post Office where 
there are 472 employees (clerks), dates the first case 
December 15th, and the week of greatest prevalence 
December 28th to January 4th, which corresponds 
pretty accurately with the hospital and medical returns ; 
29% were said to be affected, 22% were incapacitated 
and absent an average of four days ; male employees 
were most severely affected, but only 25 women are 
employed. 9 

The North End Station of the Boston Gas Light 
Company employs 320 men, and dates its first case 
December 27th, and its week of climax is given as the 
first week in January; 55% were attacked and 18% 
absent an average of three days. The Superintendent 
writes a somewhat interesting letter, to the following 
effect : 

" At the South Boston works, where thirty men 
were employed, the first case appeared December 28th, 
and it prevailed unceasingly the first three weeks in 
January ; 64% of all men were attacked, and all were 
obliged to leave work about four days. The last case 
was cured January 24th. Men who worked at the 
fires and were subjected to heat and chill, and men of 
sedentary habits were attacked. Every man in the 

In response to my request, separate return* were made up for the 
letter-carriers, 155 in number at the Central Station, who were natur- 
ally more exposed in the open air than clerks in the building. The 
weekending December 10th, a daily average of 6.31% were absent 
from duty, December 19th, G. 14%; December 27th, 6.01% ; January 
1th, 10.82%; January 12th, 11.67%; January 22d, 9.48%; January 
30th, 10.19%; February 8th, 1(1.44%. The percentage of daily absentees 
nearly doubled from the week eliding December 19th to that ending 
January 12th. The maximum week was apparently a week later 
than among the clerks. 



Vol. CXXriI, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



75 



retort houses and all the office men had it, while only 
one street laborer, and none of the yard men were 
attacked." 

The Whittier Machine Company of the Roxbury 
District, employing 261 men, presents a singular return ; 
its first case was December 22d, the week of climax 
the first in January, only \\°J were attacked and only 
2£% absent an average of seven days. The Chelsea 
Dye House had its first case December 5th, its maxi- 
mum week the fourth week in December, 40% of its 
92 employees were attacked and 35% absent an average 
of seven days. 

The average percentage of affected in eight mercan- 
tile houses in Boston, employing males, almost exclu- 
sively, is 50%. 

Medical Returns. — There are twenty-three from 
Suffolk County — all from Boston except one from 
Chelsea — which I have tabulated. 

One first case is reported December 1st, one Decem- 
ber 5th, three December 12th, but in each of these 
returns the maximum week is given as the last week 
in December. The Chelsea return dates the first 
case as late as December 25th and the maximum week 
the first week of January. 

The latest first cases returned from Boston proper 
are those dated December 20th. The greatest number 
of returns (five) giving the same date for the first case 
are for December 17th, and there are three giving 
December 16th. It would be fair to assume the 
middle of December as the date of the beginning of 
the epidemic in Boston. Ten returns give the last 
week of December as the maximum week, three the 
week from December 28th to January 4th, and three 
the first week of January. It is probably fair to assume 
that the epidemic began to decline in Boston about the 
end of the first week of January. 

It took, therefore, ten or twelve days to reach its 
climax, where it held probably five or six days. 

One return from Charlestown District gives 80% as 
the proportion of the population attacked, one from 
Brighton 75%, one from Roxbury 70%, two from 
Boston proper 65%, two 50% — these must be esti- 
mates or guesses. One return says 44% of persons in 
families visited, one 25% in families visited. The 
lowest percentage from Boston proper is 20%, and the 
lowest of all, from Chelsea, 17%. The average is 
44%. 

Sex. — Of those answering question No. 5 as to sex, 
five say male, three female, one " happened to be 
female in my practice." 

Other Diseases. — Twenty-three state that pneu- 
monia was increased (one specifying fibrinous pneumo- 
nia) ; one states that pulmonary diseases were in- 
creased ; one mentions gastritis ; only one specifies 
insomnia as a complication. In the practice of one 
there was a general immunity from other diseases 
during the latter part of the epidemic. The mention 
of bronchitis is so usual in all these returns that I 
omit it. 

As to the question of sex or exposure in the open 
air, two correlated factors as it seems to me elsewhere, 
it is difficult to draw any defiuite conclusions from the 
medical returns of Suffolk ; but it is pretty evident 
that pneumonia was increased. 

ESSEX COUNTY. 

Extending along the coast and immediately to the 
north of Suffolk, I take up Essex County next. 



I have tabulated 16 returns from manufacturing 

o 

companies, etc., in this county, and 21 medical returns 
from 14 different towns. 

A Lynn shoe shop (the only one reporting on account 
of the fire), with 210 employees, reports its first case 
January 1st, and its maximum week the second in Jan- 
uary ; the first case at the Lynn Bank was December 
28th. 

From Beverly, two shoe shops, each employing 
about 300 men, report. One says its first case was 
"about November," its maximum week the second of 
December, 90% of the employees were affected and 
75% were absent an average of ten days. The other 
reports its first case December 20th, its maximum 
January 1st, 50% were attacked and absent an average 
of four days. These shops are very near each other, 
and it is impossible to reconcile the two statements 
unless we explain the first by a "strike " rather than 
by influenza. 

From Salem, a Bank reports its first case December 
21st ; five out of six were affected ; but the Naumkeag 
Cotton Mills of Salem, with 1,078 employees, reports 
the first case "about January 1st," the maximum week 
January 4th to 11th, 40% attacked, 13% absent an 
average of five days. The Ipswich Cotton Mills, 522 
hands, same date for the first case, January 11th to 
18th for the maximum. Two mills at Newburyport, 
employing together 580 hands, report first cases Jan- 
uary 3d and 4th, maximum weeks January 4th to 11th 
and the second week of January, 25% and 43% of 
affected and absent an average of seven days. 

A Haverhill shoe shop, with 400 employees, reports 
its first case December 20th, its maximum week De- 
cember 28th to January 4th, 75% affected, 25% 
absent. From Lawrence there are two returns. Of 
the Great Pacific Mills, with 4,336 employees, very 
full, accurate and reliable returns may be found in the 
Boston Medical and Surgical Journal, Vol. CXXII, 
p. 251, to which reference will be made later. 

The first case at the Pacific Mills occurred December 
24th, the maximum week was January 4th to 11th, 
40% were affected and absent an average of 6^ days, 
females were the most and the more seriously affected. 

The Pemberton Cotton Mills of Lawrence, with 676 
employee?, report the first case December 17th, the 
maximum week January 4th to 1 1th, 41 % were affected 
(lost time in consequence) and out an average of 5 T 4 ff 
days; females were most attacked, 49% of the females 
and only 29% of the males. The report from this 
mill is also apparently accurate and reliable, and agrees 
in the main with the Pacific report. 

A linen mill at Andover, 308 employees, reports 
first case December 14th, maximum week second week 
of January, 41% attacked, 38% out. A machine 
shop at North Andover, 421 hands, all males, Decem- 
ber 25th, January 5th to 12th, 40% attacked and out 
five days. 

Medical Returns. — One return from a coast town 
(Newburyport) and one from an interior town (North 
Andover) date the first case December 1st; but the return 
from Andover, next to North Andover, dates the first 
case December 21st, and gives the maximum week as 
the second week of January, and the other return from 
Newburyport names January 1st to 15th as the maxi- 
mum period, so that these early cases may be consid- 
ered sporadic, as similar ones have been in other 
counties. 

The latest returns of first cases are from Marblehead 



76 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 24, 1890. 



and Manchester on the coast and Methuen in the in- 
terior, all January 1st ; the maximum week at Methuen 
is given as the third in January, at Manchester, Janu- 
ary 5th to 1 1 th. 

Lynn returns December 15th ; Peabody, December 
10th, with a maximum in the second week in January ; 
Dauvers, one return December 15th, one December 
25th, with the third and second weeks of January as 
maximum weeks respectively ; Gloucester, December 
18th and 24th, both returns naming January 5th to 
11th as a maximum week ; Haverhill, December 20th 
and 28th, with the first and second weeks of January 
respectively as maximum weeks. 

West Newburyport next to Newburyport, gives De- 
cember 16th as the date of the first case. 

Lawrence, December 20th, 21st and 23d, with the first 
week of January as a maximum week for the first two, 
and January 7th to 21st for the third return. 

Georgetown, in the northwestern corner of the county, 
gives December 16th as the date of its first case, and 
the middle of January as the maximum period. 

The percentages of population attacked range from 
80% in Marblehead to 5% from one return from 
Haverhill, the other return from Haverhill, giving 
23%. One return from Dan vers give 60%, the other 
10% ; one return from Lawrence gives 50%, one 
25% and one 12%. The return from Audover says 
50%, that from North Andover 15%. The average 
of twenty returns 38%. 

Sex. — Eleven returns specify the male sex in answer 
to question 5 ; three returns say females, but in one of 
these the practice is among females. 

Other Diseases. — Eleven returns state that pneu- 
monia was increased, three specify catarrhal and one 
croupous pneumonia. Eour state that pulmonary dis- 
eases were increased. Two mention gastro-intestinal 
disorders as complications. A medical examiuer reports 
two deaths without treatment, '• probably from conges- 
tive pneumonia." One return from Lawrence states 
that influenza "drove out " diphtheria which had been 
prevalent. 

MIDDLESEX COUNTY. 

This county, lying next to Essex and Suffolk, brings 
us back from the northern border of the State to the 
neighborhood of Boston. It is almost wholly an in- 
terior county, and, except for a small though thickly- 
populated territory around Boston, we take leave of 
the immediate influence of the sea. It is a manufac- 
turing population. I have tabulated 27 returns from 
factories, banks, machine shops, etc. 

From Lowell, in the northern part of the county, 
seven returns cover nearly 9,000 employees. The 
Lowell Cotton Mills, with 1,736 employees, report the 
earliest first case December 20th, with a maximum 
week the same as that in Boston, namely, December 
28 th to January 4th. I'he Merrimac Woollen Mills 
report the latest first case January 10th, with a maxi- 
mum week the second week of January; there are 
three first cases December 26th; one, December 
30th; two, January 1st; four mills give the second 
week of January as the maximum week, two mills 
January 4th to 11th, one and the Bank (only five em- 
ployees) December 28th to January 4th. 

The percentages of the affected and absent, at the 
mills in Lowell, varied very much, according to these 
returns, from "nearly every one" affected, and 50% 
absent an average of four days at the Merrimac Cotton 



Mills and Print Works, to 10% affected and 8% 
absent an average of four days at the Merrimac 
Woollen Mills. The favorable return, if accurate, from 
the Merrimac Woollen Mills was probably due to some- 
thing other than wool, for the Middlesex Woollen 
Mills report 50% affected and 20% absent an average 
of five days. 

The different departments of the same mills were as 
differently affected as the different mills. To this point 
I shall revert again later. Five days was about the 
average of absence from work. 

Sex. — As far as the Lowell returns offer any relia- 
ble information upon that point, the female sex was 
the most affected. Careful calculations from the Mer- 
rimac Cotton, with 3,200 employees, in answer to a 
special request, show that influenza " was more prev- 
alent among women and boys than among men." 

The Pepperell Cotton Mills, 316 employees, in the 
northwestern corner of the county and somewhat off 
the main line of travel, though with railroad connection, 
report the first case January 9th, and the maximum 
week the third week of January. 

The North Billerica Cotton Mills, nearer Boston 
than Lowell and on the main line of travel, with 265 
employees, report the first case " about January 1st," 
and the maximum week the third week in January. 
Next to the south, a tannery at South Woburn, 180 
employees, has its first case October 4th, its maximum 
week the second week in October, 6% attacked and 
5% absent an average of thirteen days — evidently a 
local predecessor of the great epidemic, for a Winches- 
ter factory a few miles away and still nearer Boston, 
reports its first case December 26th, it maximum week 
the first week of January. The Maiden Rubber Shoe 
Company, 1,255 employees, with dates agreeing pretty 
closely with those previously recorded in Suffolk 
County, had only 15% attacked and 12% absent an 
average of five days. The returns from manufactories 
in Cambridge, Watertown, Waltham, Newton, cover- 
ing 4,200 employees, vary but little from those given 
for Suffolk County, but the first cases are a few days 
later and the maximum weeks a few days later. The 
Nonantum Worsted Company at Newton, 520 em- 
ployees, reports its first case December 30th, its maxi- 
mum week January 4th to 11th, 17% of affected and 
absent an average of five days. 

The Waltham Watch Works, 2,300 employees, re- 
ports males as most affected. Returns from two shoe 
shops at Marlborough, 1,100 employees, report first 
cases December 22d and 26th, and the maximum week 
the first week of January and January 4th to 11th ; 
from woolen mills at Maynard, 88(5 employees, the 
first case was December 20th, and the maximum week 
January 4th to 11th; Marlborough and Maynard are 
in the western part of the Middlesex near the Worces- 
ter line. 

Medical Returns. — I have tabulated 26 medical 
returns from this county. Beginning again with 
Lowell, near the northern line, there are two returns, 
one placing the first case December 10th, and the 
maximum week the second week of January ; the 
other, December 21st. Billerica returns the first case 
December 12th, and the maximum week the second 
week of January ; from Ayer in the northwest, near 
the Worcester County line, the medical examiner of 
the district, Dr. Ilartwell, returns the first case as 
December 21st, and the maximum week the second 
week in January. lie writes : " I go into four or five 



Vol. CXXIII, No. 4.] BOSTON MEDICAL A 



ND SURGICAL JOURNAL. 



71 



adjoining towns. Ayer is a large railroad centre. The 
epidemic began here and readied its height from one 
to two weeks earlier than in places oil the line of 
travel, and, as far as my observation goes, affected a 
larger number of the inhabitants. 

" The only case I saw as medical examiner was one 
in Pepperell, said by the neighbors and thought by 
selectmen to have died from influenza, but proved, on 
examination, to have died of acute alcoholism." 

Returns from towns around Boston — Somerville, 
Medford, Melrose, Arlington, Cambridge, Waltham, 
Lexington, Concord, Newtonville, Newton — though 
varying considerably in the dates of first cases, and 
still more so in different returns for the same towns 
(Cambridge, for instance, returning November 15th, 
24th, December 1st, 23d, as dates of the first case), 
agree on the average with the Boston returns, as do 
those also of the date of the maximum week. Returns 
from Framingham and Hopkinton, in the southwestern 
corner of the county, agree as to dates with those from 
Boston. 

The percentage of the affected varies from 75% in 
five returns to 10% in two returns. It also varies 
within these same limits for different returns from the 
same place. The return of the medical examiner, resi- 
dent at Somerville, estimated 75% of the population 
attacked; another return from Somerville names 10% 
as proportion. The average percentage of twenty- 
four returns tabulated is 44%. 

Sex. — Fifteen returns specify the male sex as suf- 
fering either most numerously or most severely. Of 
these, one reads : " Males who were most exposed to 
weather and hard work " ; one return says : " In num- 
bers, females suffered more ; in severity, sexes alike " ; 
one return says : " More cases among females, more 
complications among males"; one return says: "Fe- 
males more frequently attacked, in the proportion 
of 3 : 2. 

Other Diseases. — Eleven returns state that pneu- 
monia was increased, and eight that pulmonary dis- 
eases were increased ; one return states that there was 
less pneumonia than usual ; one reply, affirming an 
increase of pneumonia, expresses doubt whether " the 
pneumonia had any direct connection with the influenza, 
or whether it was an independent disease attacking 
those already debilitated"; and another reply is ac- 
companied by this comment: "Most cases of so-called 
pneumonia following influenza are in reality cases of 
congestion, not croupous pneumonia." Another return 
states : " No diarrhoea, no constipation, no diseases 
increased in frequency or severity." 

A member of the Board of Health of Lowell writes: 
" Scarlet fever, which had been rapidly increasing for 
four weeks, with the first week in January (the maxi- 
mum week of influenza), suddenly decreased, and the 
same is true of diphtheria, though in a less degree." 
This coincides with a return from Lawrence previously 
alluded to. 

(To be continued.) 



— The Medical Record says that seventeen fatal 
cases of poisoning from antipyriue occurred in one 
week in Vienna during the prevalence of the influ- 
enza. In many of these cases the drug was bought 
by the victims themselves without a physician's pre- 
scription ; but, partly in consequence of these fatali- 
ties, it is now illegal to sell autipyrine except upon a 
written prescription from a physician. 



Original %vt\t\t$. 



COLLES' FRACTURE WITH ESPECIAL RKKER 
ENCE TO TREATMENT. 1 

ItV R. 0. HUSK, M.I)., OKOItOHTOWN, MASS. 

At the risk of being accused of pedantry, I invite 
your attention to the above subject, hoping in the 
course of the discussion of the topic to elicit some 
new facts from my brethren, while at the same time 
contributing my experience in a number of cases oc- 
curring in twenty-four years of country practice. 

Witli one exception, the clavicle, no bone is more 
frequently fractured than the lower end of the radius ; 
according to Stimson, occurring more frequently in 
elderly women. Mentioned first by Poteau about the 
year 1783, it failed to attract much notice until 1814, 
when Richard Colles succinctly and accurately de- 
scribed it, and with that degree of success that the 
title "Colles' fracture" has come down to us as a 
distinctive appellation, and serves as a monument 
to mark the wisdom and the genius of a great man. 

Probably the difficulty of thoroughly understanding 
the pathological condition of the parts arises from in- 
frequent opportunities for dissection. I may here 
remark that Professor Morton, of Philadelphia, has, 
since this was written, .January, 1890, dissected and 
reported a typical case, in which the lower fragment 
with the hand was to be plainly seen overriding the 
upper extremity. 

Certainly the fact exists that in times past many 
cases have been considered dislocations of the wrist, 
and, in consequence thereof, have been subjected to 
severe and unnecessary force for the reduction of 
the same, to the great detriment of the tendons and 
the large nerve trunks lying in close relation to the 
broken ends, the result being a far worse condition of 
affairs than if left alone, and in the same unreduced 
condition they were actually and finally left. 

Even as late as the year 1821, Sir Astley Cooper, 
one of our great surgical lights, evidently confounded 
it with dislocation of the wrist, and thought that 
powerful extension would restore the parts to their 
normal condition ; and not until 1830 did Dupuytren 
assert and maintain the fact of the existence of such 
a fracture, both evidently unaware of the discovery of 
Colles. 

Early in professional life, I chanced to see a marked 
case of Colles' fracture entirely unrecognized and con- 
sequently left unreduced, incurring great misfortune 
to the patient and no little discredit to a valued mem- 
ber of " Essex North." Not many years after, another 
worthy member was severely mulcted in damages for 
the same sin. These to me, then quite young, were of 
the nature of night-riding incubi and full of warning. 
Added to these are the unfortunate results in three 
cases of my own ; the whole serving as a stimulus to 
inquire as to the factors entering into success or the 
converse. 

Rarely, does the average doctor nowadays make a 
faulty diagnosis, the surgical landmarks being so well 
established that the fairly booked man has no trouble 
in making his diagnosis at a glance. The cause is 
almost universally conceded to be a fall upon the 
hand, causing extension or hyperextension. The 
weight anil momentum of the body being suddenly 
thrown upon the ball of the thumb, which is firmly 
1 Read before the Essex North District Medical Society. 



78 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 24, 1890. 



articulated with the trapezium and this in turn with 
the scaphoid boue which forms the chief part of the 
radio-carpal joint, transmits the whole force to the 
radius. Now a glance at the anatomy shows that 
the radius alone enters into the articulation and a still 
closer view shows that the bone is not in its entirety 
perpendicular to the blow, which, therefore, renders 
it less able to resist with integrity to its structure. 
The combined forces of the blow being transmitted at 
an angle to its perpendicular gives a cross strain which 
divulses, so to speak, the head from the shaft. The 
pronator quadratus being thus unopposed and prob- 
ably injured by the fragments tends to draw the shaft 
toward the " flexors " and laterally toward the ulna, 
allowing the lower fragment to ride upon the upper, 
hence the resemblance to a " silver fork." Now the 
ulna is about the same length as its fellow, the radius, 
and, while the latter is shortened by overriding or 
displacement, itself is forced out laterally and down- 
ward by the force and weight of the body, causing 
the characteristic deformity on the ulnar side ; and 
if the anterior and posterior radio ulnar ligaments are 
separated, then the escape of the bone from its articu- 
lation with the radius is still more marked. 

With these causes entering into a typical case of 
Colles' fracture, it may well give the practitioner 
opportunity for study and occasion for solicitude as to 
its outcome. With a case well diagnosed, treatment 
is, of course, the immediate sequence, and that has 
many and varied authorities. Stimson, as well as 
others, considers that in this fracture especially thor- 
ough reduction is essential to success. 

This might equally well be said of all fractures. 
But there seems in times past, if not in the present, 
to have been many obstacles in the way, judging from 
results in cases seen by the writer. One of the great- 
est hindrances to the reduction of the parts is their 
extreme hyperesthesia ; in fact, pain is one of the 
most constant factors in making the diagnosis. This 
renders the muscular spasm almost irresistible, and to 
mv mind goes far towards making up the frequent 
diagnosis of impaction. At any rate, it is a fruitful 
source of the violent extension and rough usage to 
which many wrists are submitted, and which are so 
depreciated by all authorities. 

To avoid these causes, fruitful of disaster alike to 
doctor and patient, anaesthesia is of the greatest ad- 
vantage. To speak from experience, my worst results 
were, in every case, put up without ; two of them, 
however, apparently being so little displaced that I 
deemed it quite possible to restore them in situ with- 
out the use of ether. These cases were all in females, 
which are, according to one authority at least, the 
most prone to bad results. Given then, a fracture of 
the wrist, presumably of the radius, ergo a Colles', 
the sine qua non is complete anaesthesia. After that 
is accomplished, it is surprising to see how a supposed 
impaction turns out to be muscular spasm; and where 
before the strongest kind of extension failed, now the 
weight of the hand almost suffices to restore the parts to 
position. And I know that in one case, merely grasp- 
ing the hand as in hand-shake, the extension not 
being noticeable, served to perfectly set the bones and 
they remained fixed. Finally, if the radius is left 
shortened, or in other words, left unreduced, just so 
much is the ulna longer, and the hand is drawn back 
to the radial side, leaving the styloid process of the 
ulna out of line with the side of the hand, so that it 



is not so much a dislocation of the ulna, as of the 
hand towards the radial side of the arm, away from 
the ulnar. 

As to the retention of the fracture many authors 
have sought out many devices, each one striving to 
carry out in his splint, the principle which avoids the 
characteristic deformity. Perhaps the most familiar 
are Bond's and Dupuytren's, both of which tend to 
draw the hand to the ulnar side with a view that 
in so doing the tendency of the ulna to protrude 
would be avoided, at the same time keeping up exten- 
sion on the radial side, which was necessary, in their 
opinion, to counteract overriding. Other splints look- 
ing more at the anatomical shape of the radius, as 
Carr's and Levis', have, in later years, received favor 
at the hand of the profession ; the former, Carr's, is 
probably the development of the shingle and piece of 
broomstick. Carr seems to have seen the need of 
support to the upper part of the radius which curves 
to quite a degree, and which in the ordinary flat 
splint is left quite unsupported, however well it may 
be padded. It is well-known and is much in use at 
the present time, it retains the parts well, but requires 
pretty frequent supervision ; it has done much, how- 
ever, towards lessening the number of deformities. 

Within a few years, Dr. Levis, of Philadelphia, 
has offered to the profession an anatomical, metallic 
splint, perforated with many holes, these perforations 
opening from within outward, serving to retain 
the bandages and at the same time contributing to 
lightness. When liued with a layer of wadding, or 
two or three thicknesses of old muslin, they are won- 
derfully comfortable, aud from their conformity to 
the shape of the limb, they give the doctor and the 
patient more of a feeling of security than any other 
contrivance. This is no small item when one lives at 
a great distance from the patient, as the writer can 
speak from experience in a case happening last winter. 

If, then, the fracture is well reduced there are sev- 
eral splints that may be of service, but to the writer 
the Levis is of great value for reasons before men- 
tioned. Freedom of the fingers is insisted on by 
many writers. This seems to me to depend upon the 
ability of each patient to move them, varying accord- 
ing to the amount of inflammation incident to each 
injury. The Levis certainly allows as much of this 
as any, and, if support for the fingers is needed, this 
splint is extremely grateful. The amount of the time 
essential to union is about thirty days ; in one case 
of my own, however, shortening and marked deformity 
began ahout the fifth week, going to the extent beyond 
the original displacement ; whether it was not reduced, 
as before hinted, or from absorption, is an open ques- 
tion. 

Since finishing this article, I have visited my two last 
cases, and find that consolidation was not complete at 
the end of five weeks in one, as evidenced by the 
gradual shortening of the radius and a consequent ex- 
tension of the ulnar. This was one of the cases which 
was unsatisfactory, being reduced without ether. The 
other case occurring at the same time in a female 
of sixty-two, with far greater displacement, is as fine a 
result as one could desire. This was reduced with 
ether. 

Within a short time, I have seen auother case 
which I had the good fortune to see at the first, but 
did not reduce, it having been attended by one of 
the oldest members of " Essex North." I suggested 



Vol. CXXIII, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



79 



murmur was heard, limited to a small area over the 
fourth left costal cartilages. Later, this murmur in- 
creased somewhat in intensity and in the area over 
which it was audible, but never became very loud or 
diffused ; it was never as loud at the apex as midway 
between that point and the base. No cardiac en- 
largement was detected, and no further murmurs were 
developed. 

December 12th, the seventh day after entrance, the 
patient called attention to a " boil " on the inner as- 
pect of his right leg, rather nearer the ankle than the 
knee. This proved, on examination, to be an abscess, 
somewhat raised above the surface, with but little sur- 
rounding inflammation, darkish in color, with under- 
mined edges. Incision was followed by the escape of 
about two ounces of pus. A similar abscess was found 
over mid-sternum, and was also opened. The next 



at the time, as he was quite muscular and there was 
much displacement, that he should not have it set 
without ether, but his surgeon said there was no call 
for it. 

This was three years ago. These is uow protrusion 
of the ulna, great weakness of the wrist, with much 
difficulty of pronation ; the most of which, I venture 
to say, would have been avoided, had reduction under 
ether been attempted. According to the patient's 
statement, much violence was used, while only partial 
success was obtained, as the result shows. 

RKSUMK. 

Colles' fracture is a divulsion of the head of the 
radius from its shaft. 

The deformity arises from the overlapping of the 
fragments, the consequent shortening of the radius 
and the dislocation of the ulna from its fellowship 
with the radius. Complete reduction is the only cure 
against deformity. This is much more easily accom- 
plished and far better results are obtained with anaes- 
thesia. 

Many cases are considered to be impaction simply 
because of extreme muscular contraction, and conse- 
quently left unreduced where complete anaesthesia 
would clear up the whole matter and bring about sat- 
isfactory results. 



A CASE OF MALIGNANT ENDOCARDITIS 
SECONDARY TO COLITIS: REMARKS. 1 

BY FREDERICK C. SHATTUCK, M.D., 

Jackson Professor of Clinical Medicine, Harvard University ; Visiting 
Physician to the Massachusetts Oeneral Hospital, etc. 

A man, thirty-four years old, a cook, of good family 
and previous history, was admitted to my ward Decem- 
ber 5, 1889. Four weeks before entrance, without 
known exciting cause, his bowels became loose, mov- 
ing sometimes eight or nine times daily without pain 
or tenesmus. A small amount of blood was noticed 
on the toilet paper, and at the end of a week he first 
inspected the dejections. He then found that he was 
passing at times fresh blood without clots, the maxi- 
mum amouut of blood being estimated by him at six 
ounces. The frequency and character of the discharges 
remained about the same until a few days before en- 
trance, when they became less frequent and less bloody. 
The day of entrance he passed, for the first time since 
the onset of the intestinal affection, a semi-solid mo- 
tion. He remained at his work until ten days before 
entrance, when pain, swelling and tenderness in the 
shoulders and right hip came on with malaise, and 
compelled him to take to his bed. 

At entrance to the hospital the pulse was 100, res- 
piration 24, temperature 101.4°. Physical examina- 
tion of the internal viscera was absolutely negative, 
except that the first sound of the heart struck me as 
rather sharp and valvular. The shoulders and the 
right hip were painful, especially on motion, and ten- 
der; the former were somewhat swollen. Under treat- 
ment, the articular inflammation gradually subsided, 
the right ankle, however, becoming involved ; the 
intestinal symptoms also abated, and within ten days 
the motions became perfectly normal in every respect, 
remaining so until death. 

The heart was carefully examined every day, and on 
the eighth day after entrance, a faint, soft, systolic 

1 Bead before the Boston Society for Medical Improvement, April 
28, 1890. 



day another abscess was found over the seventh rib in 
the left posterior axiliary line. Subsequently two more 
appeared, one on the left leg, the other on the left 
great toe. The skin over the abscesses sloughed, and 
the ulcers spread more or less in spite of the most 
careful dressing. The tissues about the abscess on the 
right leg, the first to attract attention, underwent rapid 
necrosis, and it was daily necessary to trim off an edge 
at least a quarter of an inch wide. 

By December 28th, the ulcerated surface completely 
encircled the leg, but the general condition of the pa- 
tient was better, the appetite and digestion were good, 
he read and played cards. The smaller ulcers were 
healing, and early in January, 1890, were completely 
cicatrized. The large ulcer also made rapid progress 
toward recovery, and was nearly closed at the time of 
death. 

Early in January tympanitic distension of the upper 
abdominal segment first appeared without tenderness 
and persisted, gradually though very slowly increasing 
to the end ; but the digestion remained good, and large 
quantities of nourishment were taken without incon- 
venience almost to the last. The heart grew weaker, 
a small bed-sore formed over the sacrum, finally vom- 
iting occurred, and became persistent ; nutrient ene- 
mata were not retained ; the dejections were somewhat 
loose, but normal in color and free from any gross 
abnormal constituent. 

January 14th, at 2 a. m., he died. 

Two or three weeks before death, Dr. Henry Jack- 
son, at my request, was kind enough lo make culture 
experiments with both the blood and the contents of 
one of the abscesses, which was opened at the time and 
for the purpose. The most approved methods were 
adopted and carefully carried out, but all the culture 
experiments were negative. 

Summary. — A vigorous man in the prime of life is 
taken with the symptoms of intestinal ulceration, prob- 
ably seated in the colon. After two to three weeks, a 
polyarthritis, apparently rheumatic, appears. The 
symptoms of the former soon disappear completely, 
those of the latter subside. Fever, however, persists ; 
a systolic murmur appears and gradually grows more 
distinct, but is never as loud over the mitral or basic 
valves as between them ; multiple superficial abscesses 
form and spread for a time with great rapidity, but 
ultimately heal ; tympanitic distension comes on in the 
region of the transverse colon; death occurs from 
exhaustion six weeks after entrance to the hospital, 
ten weeks after the first symptom indicative of disease. 

Clinical Diagnosis. — Malignant endocarditis, prob- 



80 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[Jolt 24, 1890. 



ably originating in the colon, causing multiple cuta- 
neous embolism. 

Autopsy. — Eighteen hours after death by Dr. Fitz. 
Head not opened. Several red patches on the skin, the 
recent ulcerations described above. Abdomen tympa- 
nitic aud distended. The pericardium contained two 
ounces of clear, yellow fluid. The heart was normal in 
size, the right side distended with clotted blood. The 
aortic and pulmonic orifices were sufficient by the hydro- 
static test. The mitral and tricuspid orifices admitted 
respectively two and three finger tips. The aortic cres- 
cents in the vicinity of the corpora aurantii were fringed 
with small vegetations along the line of apposition, to 
which small red clots were adherent. The mitral 
leaflets showed a similar fringe. The muscular sub- 
stance was an opaque red-gray in color. The lungs, 
pleura, spleen, liver, bladder and small intestine were 
sufficiently normal. The kidneys were normal in size 
and shape ; the capsule was slightly more adherent 
than usual ; on section the cortex was rather opaque. 
The transverse colon aud sigmoid flexure were both 
adherent to the abdominal wall aud adjacent coils of 
small intestine by fibrous adhesions, which were separ- 
ated with difficulty. The entire colon from the 
hepatic flexure to the rectum showed extensive ulcera- 
tion of the mucous membrane, leaving trabeculated and 
polypoid masses of relatively normal membrane. In 
places the ulcers reached the peritoneal tissue. The 
transverse colon was considerably dilated, and con- 
tained semi-solid faeces. 

Pathological Diagnosis. — Acute verrucous endo- 
carditis; chronic ulcerative colitis and pseudo-polypi. 

Malignant endocarditis may well be characterized as 
multiform as regards symptoms. At this we are the 
less surprised when we consider that in the decided 
majority of cases it is a secondary or associated condi- 
tion, rather than an independent disease ; and may, 
consequently, be overshadowed by symptoms and signs 
referable to other organs and parts. In a certain pro- 
portion of cases, any positive diagnosis is impossible 
during life; in a second category, there may be strong 
grounds for suspecting this form of endocarditis; in a 
third class, a diagnosis, nearly as certain as we can 
ever make, is to be reached. In simple endocarditis 
the diagnosis rests almost invariably on cardiac signs ; 
in malignant endocarditis these may be absent or ill- 
defined, and the diagnosis always requires and often 
rests mainly on symptoms which are either exclusively 
general, or local, and more or less widely distant from 
the heart itself. In this case, the multiple infectious 
embolism was the diagnostic sign. It should be re- 
membered that malignant endocarditis is not infre- 
quently connected with pneumonia ; that it may closely 
simulate acute mania and meningitis — even the cere- 
brospinal form of the latter — typhoid fever, even 
ague, and py;einia, of which it is to be regarded in 
some cases as a part or form ; that valves already the 
seat of a benign and more or less ancient inflammation 
are sometimes secondarily attacked by the malignaut 
process. Of the latter, Dr. Stedman's case is a good 
example. The case above reported is the fourth in 
which I have made a positive diagnosis of malignant 
endocarditis during life, with post-mortem confirma- 
tion in three. In one, seen with Dr. Humphrey of 
Lawrence who had already made the diagnosis, valvu- 
lar damage had resulted from an old attack of rheu- 
matic fever; the symptoms were distinctive enough 
and I am morally sure that the diagnosis was correct, 



though there was no post-mortem. In another case, 
the affection was apparently primary. I have seen 
other fatal cases in which I thought malignant endo- 
carditis probable ; in one patient, who recovered, the 
diaguosis was doubtful as between malignaut endocar- 
ditis and aberrant typhoid fever. The strongest point 
in favor of the latter was, to my mind, the fact of 
recovery. Most writers assert that malignant endo- 
carditis is uniformly fatal, a view to which it does not 
seem to me wise to yield unquestioned adherence. We 
are by no means sure that the benignant and malig- 
nant forms of endocarditis differ in kind ; there are, 
indeed, reasons for thinking that the difference is 
chiefly one of degree. A pathological distinction can- 
not be based on the result alone. 

The features of this case which appear to me spec- 
ially noteworthy are the following: 

In the first place, the lesson is enforced that, as Dr. 
Osier suggested, the adjective malignaut is more appli- 
cable to these cases than is the term ulcerative. The 
endocardium was nowhere ulcerated in this case, the 
heart, taken by itself, showing to the naked eye only 
changes such as might be found in any recent and 
fairly well-marked case of warty endocarditis. 

Secondly, the strict limitation of embolism to cuta- 
neous vessels is remarkable. The autopsy did not 
reveal the slightest trace of any embolic process in the 
internal viscera. 

Thirdly, the condition of the colon at the autopsy 
was remarkable, not only as presenting a rare patho- 
logical specimen, but also in that all symptoms indi- 
cating intestinal disease subsided soon after eutrance 
to the hospital. Later, marked distension of the colon 
came on, but the movements of the bowels remained 
natural to the end. 1 supposed during life that the 
distension was due in some manner to embolism of 
the bowels, a supposition which turned out to be 
incorrect. 

Finally, the failure to find bacteria, even in the 
contents of one of the abscesses, seems worthy of note. 
A similar want of result of success with the blood of 
the patient has attended the efforts of most othei 
observers. 2 

Dr. Stedman's case, which I saw twice through his 
kindness, offers some points of sharp contrast with 
mine. The clinical course was that of pyajmia, cer- 
tainly as far as the temperature went, aud the source 
of the pyajmia was referred to the heart by exclusiou. 
The diagnosis was helped by the existence of old 
aortic disease and articular symptoms which preceded 
and accompanied the early stage of the fatal malady. 
A point of great interest is that these articular symp- 
toms were again preceded by urethritis, aud the case 
might have been classed as one of gonorrhoeal synovitis 
were it not for subsequent developments. Embolism 
was absent, because no fragments were detached from 
the aortic valves, and also because the abscess in the 
heart wall had certainly no free communication with 
the arterial system. Its exact condition was impossible 
to determine on account of the preservative fluid used 
by the undertakers. 

In making our diagnosis at the first consultation, we 
attached some importance to one sign which the au- 
topsy showed to be misleading. A systolic mitral 
murmur had recently been superadded to the aortic 

« (iirode (Comp. Bend, de Soc. de Biol., 1889, p. C22) found bacilli, 
which ho was able to cultivate, in blood drawn from the arm of a 
patient with malignant endocarditis ;i few momenta before death. 



Vol. CXXIII, No. 4.J BOSTON MIWWAL AND SURGICAL JOURNAL. 



81 



regurgitant, and we were inclined to think that this, 
under the circumstances, indicated the probable impli- 
cation of the mitral valve in a recent endocarditis. 
The autopsy showed that the mitral valve was intact. 
The murmur was consequently dynamic. The, lesson 
is thus again enforced that great caution must be 
exercised in the interpretation of systolic apex mur- 
murs during pyrexia or in conditions of cardiac debility. 
The former was present at the time of the first consul- 
tation, but the heart was acting with perfect regularity 
and apparently sufficient force, eighty-four beats to 
the minute. In this case again the chief diagnostic 
sign was outside of the heart, namely, the irregular 
rigors. Add to this the presence of an old endocar- 
ditis, or rather its remains, and the diagnosis was 
practically certain. 

Note. — Since the above case was reported, the writer has 
seen a number of times, with Dr. Garland of Boston, another 
well marked case of fatal malignant endocarditis originating in 
gonorrhoea. 



OBSERVATIONS ON A CASE OF PERITYPHI- 
LITIS. 1 

BY JOHN ROMANS, 2ND, U.S. 

A. B. was a large stout man, of great physical 
strength and vigorous appetite, who led an exception- 
ally active and busy life. Some fourteen years be- 
fore his death he was seized with a violent pain in the 
right iliac region, accompauied with some diarrhoea 
and the presence of a small, hard painful swelling sit- 
uated on a level with, but towards the umbilicus from 
the right anterior superior spine of ilium. Owing to 
the extreme deposit of fat on the abdominal walls it 
was difficult to ascertain the evact size of the tumor 
which, however, seemed to be about as large as the 
palm of a boy's hand, with a sharp upper outline, and 
impressed the observer, Dr. John Homans, as being 
a sort of cake of inflammatory material. There was 
little or no fever, the acute pain lasted some five or 
six days and then gradually subsided, the swelling 
slowly disappearing as the pain grew less. 

From this time on the patient had several attacks, 
some five or six in number, of the same nature as 
that just described, save that they grew more severe 
and that the inflammatory cake increased in sizie till 
in the last attack in which I observed him it extended 
nearly to the umbilicus, and seemed to run under the 
edge of the floating ribs, the well-defined outline be- 
fore described no longer existing. Whether this cake 
persisted in the intervals of the attacks it was impos 
sible to say ; but the patient suffered occasionally 
from diarrhoea which would last a few days, and was 
always accompanied by pain in the right groin. 

During the last few years of the patient's life he 
met with one or two quite severe accidents, and con- 
tracted a specific infection, which, however, troubled 
him little after the earlier secondary symptoms. His 
final illness was a most severe attack of jaundice, the 
discoloration and itching of the skin being extreme, 
and the mental depression, languor, headache and all 
the other well-known cholaemic discomforts were 
present in a marked degree. His strength was grad- 
ually undermined and he died rather suddenly at last, 
having been sick about six weeks. 

1 Kead before the Boston Society for Medical Improvement April 
28, 1K90. v 



The autopsy (for notes of which I am indebted to 
Dr. Morris Longstreth of Philadelphia) showed noth- 
ing remarkable save the results of the intense chola:- 
mia till the abdominal cavity was opened. 

The omentum was rolled up and adherent to the 
border of the liver at the fissure of the gall-bladder, 
on the right side over the region of the caput colli 
the peritoneum of the anterior abdominal wall was 
thickened and rough and a portion of the omentum 
still adherent, the result of former inflammation. 
Around the caput colli and ileum were numerous old 
adhesions and bands, and the appendix was concealed 
from view by the mass of old inflammatory structures. 
It did not present any appearances of ulceration or 
perforation. 

Stomach, liver and duodenum removed en masse. 
The latter was drawn up close under the liver, and 
the tissues surrounding the common bile-duct from 
beginning to end were greatly increased. They pre- 
sented themselves as a mass measuring over two 
inches in cross-section. A considerable portion of 
this mass was composed of fat and several lymphatic 
glands held in very dense connective tissue, much 
firmer than usual in this situation. The opening of 
the common bile-duct on the surface of the duodenum 
could be detected by the eye and was not eroded or 
ulcerated. A probe passed up the common duct 
entered easily into the hepatic duct and into the liver, 
but could not be made to enter the cystic duct. The 
gall-bladder was found in the midst of the adherent 
omentum and mass of connective tissue described 
above, and presented itself as a yellowish-white body 
of less circumference than the little finger one and 
one-half inches in length, the fundus being about two 
inches from the border of the liver ; on section no fluid 
ran. Cavity coutaiued perhaps twenty gall-stones, 
one the size of a small pea, but mostly about the size 
of head of an old-fashioned brass pin. These were 
imbedded in a yellowish gelatinous mucus. Probe 
passed from the gall-bladder towards the cystic duct 
tailed to enter, and dissection showed that the duct 
was closed and converted into a fibrous cord sur- 
rounded by the mass of connective tissue around the 
common duct. The liver on section presented a 
pretty uniform appearance save for some slight evi- 
dences of fatty degeneration. The interacinous con- 
nective tissue was not increased. The portal veins 
were normal. The other abdominal organs presented 
nothing remarkable. 

In this case, then, there existed for many years about 
the caput colli a nidus of inflammation which, after 
irregular periods of torpidity, would suddenly become 
active, giviug rise to the attacks described above, ex- 
tending its limits with each successive attack, forming 
adhesions, causing an increase in connective tissue, 
till finally the structures thus formed by inflammatory 
action seized upon the gall-bladder and duct and 
death followed. 

It is interesting to consider whether the result of 
this case would have been different if the operation 
recommended by Treves had been performed and the 
appendix removed in the intervals of the attacks. 

Against the sanction of Treves's operation in any 
case, I think there are two strong arguments, the first 
of which applies with equal force to Tait's procedure 
of catheteriziug the appendix and pressing back the 
foreign body, if any exist, into the caecum. These 
arguments are, first, the difficulty of finding the appen- 



S2 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[Jult 24, 1890. 



dix ; second, a doubt whether the mere removal of 
the appendix will insure cessation of the attacks. 

It is by no means an easy thing to find the appen- 
dix in a fulminating case, when the adhesions are 
recent and easily broken down and the anatomical 
relations of the parts not much disturbed, but in this 
case, for instance, with the old, tough adhesions mask- 
ing the site of operation, the surgical procedure would 
have been more or less blind and the discovery of 
the appendix almost more a matter of chance than 
skill, involving an amount of handling and general 
turning over of the intestines which would have 
materially affected the chances of recovery. It should 
be borne in mind also that the appendix is frequently 
found in abnormal situations by surgeons who are 
operating during a first attack. Thus it has been 
found in the median line, or uear the umbilicus. 
I have discovered it at autopsy hanging down in the 
pelvis, bathed in pus and nearly touching the rectum, 
and Dr. G. H. Monks, in a recently reported case, 
removed the appendix from a tumor of the scrotum. 

It is probable that wherever the appendix was car- 
ried by the inflammatory process, there or thereabouts 
it would remain, and its change of position would be 
so great that the landmarks would be partially oblit- 
erated. 

Granting, however, that the appendix has been 
successfully removed, or its calibre occluded by stitch- 
ing, as Tait recommends, can a positive assurance of 
freedom from further attacks be given ? This ques- 
tion must, I think, be answered at present in the nega- 
tive. In Treves's and Tait's cases a sufficient time 
has not yet elapsed to make them of any value, and 
the case described above, at first sight a most favorable 
one for the operation, would most probably not have 
been materially aided as, judging from the autopsy, 
the appendix does not seem to have played a major 
role in the causation of the trouble after the first at- 
tack. Treves's or any operation would have to be 
done early to be of any especial advantage and at this 
time patients would not be apt to present themselves, 
while after three or four attacks the amount of inflam- 
matory structures would be so great and the innerva- 
tion of the organs so affected that the mere removal 
of the appendix would not be sufficient to stop the 
trouble. If, then, a patient recovers from one or two 
attacks under medical treatment and then seeks relief 
during the interval through surgical aid, there is a 
strong probability that the operator by not finding the 
appendix in its normal surroundings may subject his 
patient to an operation dangerous because of its length 
and the resulting shock (to say nothing of a possible 
hernia through the scar), which operation would not 
promise any immunity from the disease. 



MALIGNANT ENDOCARDITIS; DEATH; AU- 
TOPSY. 

BY C. ELLEKY STEDMAN, M.D. 

A. B., merchant, aged forty-seven, was subject to 
rheumatism, and had an acute attack some years ago, 
which left him with a diastolic raarmur under the 
right clavicle. In August, 1889, he had suffered, as 
had a brother and sister, from renal calculus. . . . 
In September, he had arthritis in left elbow and right 

' Read at the meeting of the Boston Society for Medical Improve- 
ment. April 28, 1*90. 



foot, with considerable pain. The attack was sub- 
acute, easily yielded to salicylate of sodium, and lasted 
ten days. He returned to his counting-house at once, 
and on the third of October I was desired to see him 
again. He had had a chill, sweating, and high fever; 
complained much of the right ankle, of great weak- 
ness, headache, constipation, and a little confusion of 
mind. The temperature was 103.2°, the pulse 90, 
strong and regular. The murmur continued under 
the right clavicle. At six the same evening the tem- 
perature was 104° ; at ten the next forenoon it dropped 
to 97.6°, with sensation of chilliness. The next day 
it ranged from 100° to 102.4°; and the following 
twenty-four hours between 100° and 101°, with amel- 
ioration of all symptoms. On the eleventh day of the 
disease the fluctuations of the mercury were from 
99.2° to 103° ; and on the thirteenth there was a fall 
from 104° at noon to 97.5° the next forenoon ; in the 
night of the fifteenth day there was a rigor at 99.6°, 
and the next morning the thermometer indicated 
104.6°. On the thirty-fifth day the temperature 
ranged between 99.8° and 105.8°, the highest reached. 
Delirium was first noticed on the sixteenth day, and 
was more or less present during the sickness; vomit- 
ing was infrequent. The tongue was clean and moist 
till the last week of his life, and his expression did 
not greatly alter. There was much irritability, little 
disturbance of vision, no cyanosis. The rheumatic 
pains disappeared after the first week as do the rachi- 
tic pains of typhoid fever. 

It was near the end of the first week that a new 
cardiac murmur was noticed with the systole at the 
apex ; the apex was not easily defined, the area of 
duluess seemed slightly increased. In the aortic area 
there was on the twentieth day a slight systolic mur- 
mur propagated upwards, a loud diastolic sound down- 
wards ; in and about the mitral area was heard an 
aortic systolic murmur not present when this illness 
began ; a slight crepitus was heard in the middle of 
both backs. At this date there was no swelling of the 
abdomen, no spots on the skin ; the epigastric and 
cremasteric reflexes absent; the plantars responsive; 
answers and questions were prompt and accurate, 
though the patient seemed apathetic. On the thirty- 
fourth day he was harassed by cough increased by 
lying on his side, and without expectoration ; his 
tongue was coated ; the liver below the margin of the 
ribs a little tender, as was the region over the heart ; 
the mind not wholly clear ; the jugulars slightly dis- 
tended ; the first sound at the apex and the systolic 
murmur less distinct ; some crepitus in tricuspid area ; 
dulness of left back, with general crepitus, also pres- 
ent in the front to a less degree. On the thirty-fourth 
day there was an involuntary dejection. From the 
thirty-fifth to the thirty-ninth day there was a gradual 
fall of temperature from 105.8° to 97.6°, from which 
it shot the next day to 103.5°, and then decreased 
till the forty-fourth day, on which he died. 

The autopsy was made twenty-four hours after death, 
in my unavoidable absence, by Dr. S. Crowell, to whom 
I am obliged for the following notes. Drs. Benjamin 
Gushing and F. C. Shattuck were present. 

The pleura, pericardium and peritoneum contained 
some fluid light in color, partly due, doubtless, to the 
undertaker's operations. Kidneys enlarged, dark in 
color; one contained numerous uric acid calculi, other- 
wise normal. Liver enlarged, witli nutmeg appear- 
ance. Spleen enlarged, dark red, friable ; had an old 



Vol. CXXUl, No. 4.] BOSTON MEDICAL AND SUMG1CAL JOURNAL. 



83 



infarction. The lungs were not adherent to the 
pleura; no indurations in their substance, air and fluid 
being squeezed from them. The heart enlarged, the 
aortic cusps were rather thickened, insufficient, and 
the seat of numerous warty vegetations, one of which 
hung freely movable on its pedicle downwards toward 
the ventricle. This vegetation, in striking against the 
cavity opposite its attachment, seemed to Dr. Fitz 
(who studied the specimen later), to have lighted up 
inflammation, which resulted in a myocarditis and ab- 
scess ; pus of a dark color, and mixed with a degener- 
ated necrotic tissue, issued from an opening in the 
ventricular wall ; the pus cavity in the heart muscle 
was over an inch in depth. 

I was efficiently aided in this case by the support 
and counsel of Drs. Gushing and Shattuck. 

The patient presented no signs of anything more 
serious than the ordinary rheumatic endocarditis till 
the second week. After the first visit the temperature 
was not remarkable for six days ; then it took its 
flight upwards to 104°, and the systolic murmur was 
added to the diastolic. The patient's family had suf- 
fered a sad experience with typhoid fever, and were 
impressed with the similarity of the symptoms to those 
they had been frequently called on to witness. A phy- 
sician not familiar with the patient's history might have 
easily been misled about the character of the disease ; 
and the strong, good pulse would have justified a favor- 
able prognosis nearly to the end, had not the condition 
of the heart (of which there was no complaint or sign 
except the physical ones) been suspected. 



LARGE PAPILLOMATOUS CYST WITH ASCITES; 
LAPAROTOMY; WOUND OF THE BLADDER 
WHICH LAY UNUSUALLY HIGH; SUTURE 
OF IT WITH COMPLETE RECOVERY. 1 

BY A. T. CABOT, A.M., M.D. 

In June, 1889, 1 saw Mrs. H. F. H., in consultation 
with Dr. H. W. Boutwell of Manchester, N. H. The 
patient was an emaciated women of fifty-two. Her 
menses had ceased when she was forty-four, and she 
had been in apparent good health until one year before 
my visit, when she noticed that her abdomen was in- 
creasing in size. This enlargement was at first more 
noticed in the right side than in the left. She steadily 
lost in flesh and strength during the year and the 
swelling as steadily increased. Six weeks before she 
came under observation the legs became swollen, and 
a large protrusion of the vaginal walls became very 
troublesome. The pressure upward became so great 
that she suffered greatly from dyspnoea and was unable 
to lie horizontal. 

When seen, the abdomen was enormously distended 
with ascitic fluid, so that examination by palpation was 
extremely unsatisfactory. 

Nothing could be detected in the heart nor in the 
condition of the urine to account for this accumulation 
of fluid, and there was nothing in the symptoms to 
point to the liver as the seat of trouble. In the ab- 
sence of evidence in any of these directions, it seemed 
very probable that an abdominal tumor had given rise 
to, and was now masked by the ascites. This suspicion 
was strengthened by the patient's observation that the 
swelling of the abdomen had started in the right side, 
and had afterwards become general. 

1 Read before tUe Boston Society for Medical Improvement, April 
28, 1S90. 



With the object of further observation she was sent 
to the Massachusetts General Hospital. 

On June 27, 1889, J tapped the abdomen and drew 
off sixteen quarts of dark, brownish fluid which con- 
tained many blood-cells and some large compound 
granule cells. After the removal of the fluid, a tumor 
as large as an adult head came into view, rising up out 
of the pelvis, and a little to the right of the median 
line. Portions of this felt elastic, as if cystic in char- 
acter ; but the larger part of it, especially that portion 
towards the pelvis was quite firm. It was so fixed in 
the pelvic region that it altered its position but little 
on change of position. 

A strong suspicion of malignancy was entertained, 
both on account of the physical qualities of the tumor, 
and from the character of the fluid removed. It was, 
however, decided to do an exploratory operation and 
to remove the tumor if it were found possible. 

July 5, 1889. Laparotomy was done. The incision 
was made midway between the pubes and umbilicus. 
At a distance of four and a half inches above the upper 
edge of the pubes the incision which was carried straight 
down through the abdominal wall, opened the bladder, 
without entering the peritonenm. This opening was 
closed by an interrupted suture of fine black silk, and 
then the peritoneum was opened in the upper part of 
the wound. The tumor, which was very adherent in 
the pelvis, was peeled out after some difficulty ; and 
there being some persistent oozing of blood from the 
separated adhesions down in the pelvis, a glass drain- 
age-tube was put in and the abdomen was closed by 
interrupted silk sutures including the peritoneum. 

The turner was a multilocular cyst, with considerable 
papillomatous growth in the lower portion. This 
papilloma had nowhere broken through the cyst wall, 
nor implicated the peritoneum. 

The recovery was uneventful, though somewhat 
slow on account of the weakness of the patient. The 
urine was drawn through the catheter for the first week 
and some irritability was caused by this frequent 
catheterization. The bladder suture held perfectly, 
however, and the wound healed by first intention. 

This case was interesting for several reasons : The 
diagnosis was difficult as the tumor could not be felt 
while the ascites was present, and after the fluid was 
drawn off, the character of the tumor and its firm ad- 
hesion to the pelvic organs made it seem malignant. 
This suspicion was strengthened by the bloody charac- 
ter of the surrounding fluid. The result of the opera- 
tion shows the importance of doing laparotomy in all 
cases in which there is a possibility of doubt as to the 
kind of tumor or the feasibility of its safe removal. 

The position of the bladder in this case was quite 
exceptional, and led to its being wounded by an in- 
cision at a point where there was no reason for antici- 
pating such a danger. 

Usually when the bladder is wounded in laparotomy, 
the injury passes through the peritoneal surface, and 
after suturing, the adhesive inflammation of the peri- 
toneum greatly promotes the adhesion of the wound. 
In this case the incision did not go through the peri- 
toneum, but only involved the connective tissue in front 
of the bladder. It was like the wound made in supra- 
pubic lithotomy, and in these wounds, primary intention 
is much rarer than in injuries to peritoneal surfaces. 

Care was taken in applying the sutures, to include 
all of the outer layers of the bladder wall, but not to 
penetrate the mucous membrane. 



84 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 24, 1890. 



The accumulation of urine in the bladder was pre- 
vented by frequent catheterization, and the ready heal- 
ing shows that no leakage took place. 



Keport# of ^ocietieg. 



BOSTON SOCIETY FOR MEDICAL IMPROVE- 
MENT. 

G. G. SEARS, M.D., SECRETARY. 

Regular Meeting, April 28, 1890, the President, 
Dr. W. L. Richardson, in the chair. 
Dr. A. T. Cabot showed a 

PIECE OF CATHETER 

about four inches long, which he had removed from 
the bladder of a man of seventy. The specimen was 
interesting as showing how rotten one of these web 
catheters becomes in the bladder, and how easily they 
may be cut up and removed with a lithotrite. It must 
rarely happen that a supra-pubic or other cutting 
operation is needed for the removal of such a frag- 
ment. In this case a stricture of the urethra some- 
what complicated matters. This was divulsed as the 
first step in the operation ; and the reporter said that 
he preferred divulsion to urethrotomy in such cases, 
where he was going to pass the instruments through 
the urethra afterwards, as he thought divulsion left 
the passage smoother, with less likelihood of there 
being pockets in which instruments might catch. 
Dr. Cabot reported a 

a case of suture of the bladder 1 

for a wound made during a laparotomy for a large 
papillomatous cyst. 

Dr. J. Homans, 2nd, reported 

a case of chronic perityphlitis. 2 

Dr. Cabot : One point which Dr. Homans made is, 
it seems to me, an important one, and one in which I 
should differ decidedly from him, that is, that this 
condition of the appendix which was found at the au- 
topsy showed that the appendix was not the cause of 
each individual attack. We know from recent cases 
published in the journals, how even a comparatively 
short time, a few weeks, after an attack which was 
evidently caused by the appendix, the appendix has 
been removed and there has been no ulceration 
through its wall, and it seemed in a tolerably normal 
condition, slightly thickened as to its walls, but not 
otherwise altered. I think the power of reparation 
is very great in the appendix ; and it does not seem to 
me impossible that the cause of each of these attacks 
was ulceration of the appendix, which subsequently 
healed, and that an adhesive inflammation started from 
this ulceration, and left the cake of tissue which was 
described. 

Dr. F. C. Shattuck : The reader mentions an 
intense jaundice, and yet the commou duct seems to 
have been patent. Is there any report as to the cause 
of that jaundice ? 

Dr. Homans : A probe could be passed at the au- 
topsy, but the supposition was that the mass of con- 
nective tissue, by the mere force of its pressure, closed 
it so that the flow of bile was stopped. 

1 See page 83 of the Journal. 

2 See page 81 of the Journal. 



Dr. Cabot : In connection with the question of 
removal of the appendix and the severity of this oper- 
ation, I should like to report a case I had early in the 
year, in which, upon removing a malignant tumor of 
the ovary, the appendix was found buried in the 
tumor. I first dug out the piece of tumor growing 
into and upon the appendix, and laid it to one side 
while I removed the mass of the tumor. Afterwards 
I tied the appendix off at its junction with the head of 
the colon, and then inverted and stitched the end so 
as to bring the serous coats approximately together. 
In that case, as in many of the other cases of removal 
of the normal appendix, there was no reaction. The 
case did perfectly well, and it seemed as if the inter- 
ference with the appendix had added nothing to the 
severity of the operation. I think that the removal 
of the appendix is an operation of comparatively little 
severity. 

Dr. Homans : My idea was, that as a result of 
three or four attacks there would be various bands of 
adhesions, with certain amount of abnormal structures, 
and that the whole would be in a state of sub-acute 
inflammation all the time. The mere removal of the 
appendix will not straighten out those bauds. It 
would be the same thing as a man who has had a 
severe attack of pleurisy where, the adhesions still 
remaining, and portions of the lung still compressed 
perhaps, those adhesions always stay, and he is liable 
to have another attack : so it seems to me, with the 
coils of intestine lying round and adhesions going 
from one to the other, that there is left behind an 
amount of inflammatory structure of abnormal condi- 
tion after the appendix has been removed. It does 
not seem probable that the removal of the appendix 
will prevent the recurrence of attacks, though it may 
make them somewhat less likely to occur ; yet I should 
say it would affect the chances of their recurring to a 
comparatively small extent. 

Dr. Cabot : Do you think the inflammatory adhe- 
sions left there are themselves the source of inflam- 
mation subsequently ? 

Dr. Homans : The source of pain. They might 
cause a slight kink in a coil of intestine. 

Dr. Cabot : I agree to that, but I think the appen- 
dix is, with few exceptions, the cause of the recurring 
attack. 

Dr. C. E. Stedman 3 and Dr. F. C. Shattuck 4 each 
reported 

a case of malignant endocarditis. 

Dr. B. Cushing read a case with autopsy showiug 
how extensively the heart may be diseased without 
constitutional symptoms. 

Dr. Cabot: In Dr. Cushing's case the murmur 
was a very loud systolic one, difficult to locate. We 
had no stethoscope with us so that we relied upon our 
ears. That and one other case are the only instances 
of malignant endocarditis I have seen, and unfortu- 
nately in the other one there was no autopsy obtained. 
I saw the case for my father in his absence and he 
subsequently took charge of it. The first symptoms 
were those of bronchitis. On examination 1 heard a 
systolic murmur over the aortic valve which lasted a 
few days and disappeared ; never to be reproduced. 
The patient ran down with rather high temperature, 
and had, I remember, an abscess over one malleolus 

• See page 82 of the Journal. 

* See page 79 of the Journal. 



Vol. CXXIII, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



85 



aud another on the top of the head, with one or two 
others at different points under the skin. 

Dk. Bi.odgett: I am reminded by the very inter- 
esting cases which have been reported to-night of the 
first case of this disease of which I have any knowledge 
as having been reported in this vicinity, which oc- 
curred some years ago in the practice of Dr. Grace 
Wolcott. The patient was a woman about forty 
years of age, who had had the preliminary symptoms 
referable to rheumatism, which have been mentioned 
as preceding very often cases of endocarditis of this 
character. Dr. Wolcott noticed, soon after, the oc- 
currence of a mitral murmur, which had not hereto- 
fore been present, and which increased from day to 
day for several days. By the kindness of Dr. Wol- 
cott I saw the case in consultation, and we both ar- 
rived at the same opinion, that it was a case of pro- 
gressive endocarditis ; aud we could account for its 
peculiar symptomeu-complex in no other way than by 
the supposition that acute inflammatory and destruc- 
tive processes were going on in the heart, producing 
the murmur which increased from day to day. The 
patient lived about ten days from the discovery of the 
cardiac murmur, and death took place from the lesion 
of the heart, as I remember it, more than from auy 
other ascertainable cause. In this case there was the 
foudroyant course of the disease, and it was accompan- 
ied with symptoms of acute septic infection. No at- 
tempts were made to cultivate bacteria. There were 
frequent chills and symptoms similar to those which 
would accompany pyaemia in any other part of the 
body. The heart was removed and presented before 
the Clinical Section at the time at which the case was 
reported. The heart presented, as I remember it, a 
distinct perforation through the substance of the mi- 
tral valve, of ulcerative character with ragged edges 
and the appearance of inflammatory conditions affect- 
ing the free edge of the valve, and to some extent, 
the chordae teudineas. 

I have during the past winter had a case that re- 
minded me of ulcerative endocarditis which has fol- 
lowed another course. A lady of about twenty-two 
years suffered from the prevailing epidemic in Decem- 
ber, but was not confined to her bed. I was called to see 
her some days subsequently when she had been pros- 
trated by a chill, and I then found the evidences of 
acute pneumonia confined to the left lower lobe. It 
ran its course in the ordinary way. On the fifth day 
a systolic murmur was heard over the base, which I 
had not been able to detect before, and concerning 
which no history of previous heart disease was ascer- 
tainable. I felt quite certain that if any condition 
referable to the heart had previously existed it would 
have been discovered. That murmur increased for a 
certain number of days and at the end of a fortnight 
was at its height, remained persistent several weeks 
and gradually diminished ; but during its subsidence 
there occurred an acute inflammatory process located 
in the region of the left ovary, and which I thought 
was connected with the ovary. I made no vaginal 
examination, but by the application of hot poultices, 
the administration of anodynes, and by other measures 
which suggested themselves from time to time as the 
case progressed, the inflammation finally subsided, the 
swelling was reduced and the local process became very 
much better. Following this there developed a typical 
phlebitis of the left leg, which ran its course in about 
four weeks, and from which the lady is still suffering. 



This case corresponds very well I think with some 
that have been reported of supposed malignant or 
perhaps, ulcerative processes of the heart with subse- 
quent inflammatory or septic affections of various 
parts of the body. It would seem very possible in 
this case to depend upon a cardiac lesion which had 
not previously existed, which was present to a certain 
extent during a considerable interval, aud which sub- 
sided until its presence could not be detected. Whether 
that is a case of the character mentioned to-night as 
among those who recover from this disease I may 
never be able to ascertain. I present it as a possible 
case in which the chief symptoms of that rather nn- 
common disease were present, and it is the only case 
that has ever come under my personal observation in 
which recovery has followed. 

Dr. F. C. Shattuck: Patients have been sent to 
insane asj'lums as suffering from acute mania whose 
disease was malignant endocarditis. A very interest- 
ing case of this affection in which such a mistake was 
made was reported by Dr. Truax in the Section of 
Clinical Medicine at the last meeting of the American 
Medical Association at Newport. With regard to 
Dr. Blodgett's case there are two points that strike 
me : one is the great care that we must exercise in 
the interpretation of systolic murmurs. A diastolic 
murmur is on the chances organic, but so many sys- 
tolic murmurs are dynamic or hseuiic that I think we 
have got to be pretty careful about them. This very 
winter a patient at the hospital — I forget what the 
disease was — during the last few days of life devel- 
oped a tremendous to-and fro murmur over the heart, 
harsh, rasping. At the autopsy the heart and peri- 
cardium both were normal. In Dr. Blodgett's case I 
suppose he would hardly attribute the swelling of the 
leg to embolism. Thrombosis would seem to be the 
more probable cause. 

Dr. Blodgett : I considered the first inflamma- 
tion in that region as probably the cause of the throm- 
bosis of the vein, not an embolism of the artery. 

Dr. Whitney showed a specimen of 

OSTEO—CHRONDRO— MYXOMA OF THE RIGHT THIGH. 

The history is briefly that of a man who, for the 
last four years, has had a rapidly growing tumor of 
the upper part of the right thigh ; and which, when 
first seen a short time ago by Dr. S. J. Mixter, was 
considered inoperable. The foot was everted, aud 
the posterior part of the growth ulcerated and necrotic. 

At the autopsy made to-day by Mr. F. B. Mallory, 
of the Medical School, the head of the bone and ace- 
tabulum were found to have been destroyed ; but the 
pelvis itself had not been perforated, and there was 
no internal metastasis. The bulk of the growth 
was made up of a soft gelatinous aud sago-like looking 
material, covered by a sort of harder outer shell, in 
which were plates of bone, the thickest and largest 
forming a continuous, more or less irregularly flattened 
outgrowth from the shaft of the femur. Microscopic 
examination showed this to be made up of a homoge- 
neous ground substance, giving a reaction for mucin. 
In this were imbedded numerous round, spindle and 
star-shaped cells anastomosing by long, very fine fila- 
ments. In places areas of true cartilage were met 
interspersed with bone. So that the growth should 
properly be called an osteo-chrondro-myxoma. The 
starting place is either from the medullary canal or at 
the point where the head joins the shaft. But at 



86 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 24, 1890. 



preseiit it is impossible to say which, as the destruc- 
tion and new formation of bone have been so exten- 
sive. 



THE NEW YORK ACADEMY OF MEDICINE.* 
SPINAL surgery: a report of eight cases. 

The next two cases, Dr. Abbe said, were of unusual 
interest, as they showed a field in which the extreme 
nicety of diagnosis does credit to the physicians in 
charge, and surgical relief follows closely. 

Case V. Extra-dural tubercular tumor of the spine ; 
complete paraplegia ; operation ; recovery. 

The patient, twenty-two years of age, was taken with 
pain in his back in January, 1 ">88, and admitted to St. 
Luke's Hospital in March. The spine was flexible, 
and without deformity, though a very slight fulness 
was seen in the soft parts to the right of the ninth and 
tenth dorsal spines. During March the sense of touch 
was dull in his legs, and the muscular power somewhat 
weakened. A line of hyperesthesia formed about his 
waist. Two weeks later he could not stand without 
support, and he had uncontrollable twitchings of the 
legs, which had become quite anaesthetic. He had 
constant intercostal pain, with girdle pains about the 
limiting line of disease. Incontinence of urine and 
faeces followed ; an active hectic set in, and he rapidly 
wasted away. During the week before operation he 
failed so rapidly that death seemed imminent. 

On May 2G, 1888, Dr. Abbe made a free incision and 
removed the spines and arches of the eighth, ninth, 
aud tenth dorsal vertebrae. Outside the carious arch 
of the ninth was a half-ounce of thick pus ; but within, 
aud filling the vertebral canal, was a small quantity of 
inspissated pus and a large amount of dense neoplasm, 
evidently tubercular. It extended up and down the 
canal for two aud a half inches, and it was thoroughly 
curetted from the cord by Volkmann's spoon, until 
sound bleeding tissue was left on every side. The cord 
was firmly compressed against the anterior wall of the 
canal. The wound was lightly packed with iodoform 
gauze, and allowed to granulate ; and a plaster jacket 
was applied over all. The patient made a rapid and 
complete recovery, and remained perfectly well in every 
respect for more than a year. Recently, after the con- 
finement of the winter, he has had an abscess form in 
the cicatrix which had been so long healed, and Dr. 
Abbe has had to curette a sinus remaining from it 
which led down to the bone. There has been no 
affection of the cord, however, aud he hopes very soon 
to heal the sinuses, though they have a distinctly tu- 
bercular appearance. (This patient was shown.) 

Case VI. Pressure paraplegia from extra-dural 
sarcoma; operation, with complete removal of the 
tumor ; death on ninth day. 

The patient was forty-two years of age. Three years 
ago, while placing a pedal under a heavy piano, the 
instrument was let down and pressed heavily on his 
back, and he suffered pain from this for several days. 
Six months later, while lifting the corner of a heavy 
piano, he was caught by an excruciating pain in the 
back. In January, 1889, he twice jarred his spine 
severely, and in July of that year he first felt a decided, 
though not severe, pain in his back at the site of the 
present trouble. After this, paralysis of the lower 
part of the body came on, and in October, 1889, he 

1 Report of Meeting of May 15, 1890. Concluded from page 65 of 
the Journal. 



was seen in consultatiou by Dr. E. C. Seguin, who 
made a diagnosis of pressure paralysis and advised 
early operation. In January, 1890, the patient was 
brought from his home in Toronto to New York, and 
placed under the care of Dr. R. F. Weir. Drs. Seguin 
aud Weir found on examination a slight fulness of the 
eighth dorsal spine, and advised a month or six weeks 
of orthopedic treatment ; hoping that the pressure 
might be from Pott's disease and that a natural relief 
of intravertebral pus might put an end to the paraple- 
gia without operation. The treatment adopted was 
followed by no improvement, and during its continuance 
he had a fortnight's illness with acute nephritis and a 
temperature of 102.5° Dr. Weir having gone to 
Europe the case was transferred to Dr. Abbe. On 
March 20th, the day before it was arranged to operate, 
he had an unaccountable chill, with a temperature of 
104°. This attack lasted two weeks before his tem- 
perature became normal, and it, as well as the previous 
one, was probably due to slight septic infection. 

On April 16th, Dr. Abbe operated. On removing 
the arches of the eighth, ninth, and tenth vertebrae 
and the pedicle of the eighth, a firm dark growth was 
found to fill the vertebral canal, compressing the cord 
to the left side and flattening it somewhat forward; so 
that it represented scarcely more than half its normal 
bulk. It was readily removed by blunt resection from 
the dura, which was left with a quite natural appear- 
ance. The growth bulged backward between the 
arches, laterally between the pedicles, which it softened, 
and forward into the body of the eighth vertebrae and 
at one side into the sub-pleural space ; and from all 
these sites it was removed by Volkmaun's spoon. Not 
a trace of pus suggestive of tubercular caries was any- 
where seen. The wound was packed loosely with 
iodoform gauze. The patient endured the operation 
very well and was in excellent spirits for four days 
when hiccough and vomiting set in. He finally became 
so exhausted by these that he died on the ninth day ; 
death being preceded by delirium. The muscles of 
the legs began to react to electricity on the fifth day ; 
but no return of sensation or voluntaiy motion. The 
tumor was carefully examined by Dr. J. S. Thacher, 
who found it to be a round-celled sarcoma, without 
trace of leucocytes, giant cells, or tubercular material. 

Dr. Abbe said this case was of special interest as 
illustrating the differential diagnosis between myelitis 
of the cord and pressure of the paraplegia of tumor, 
and he read a letter which he had received from Dr. 
Seguin relative to that question. 

Case VII. Intractable brachial neuralgia ; nerve 
stretchiug, amputation, and finally iutra-dural division 
of the sixth, seventh aud eighth cervical nerves. 

Case VIII. Intractable brachial neuralgia ; intra- 
dural division of the posterior roots of the sixth, seventh 
and eighth cervical aud first dorsal nerves. 

In neither of these cases was the result of the opera- 
tion very satisfactory, though the pain appeared to be 
very much less intense and of a different character 
from that experienced before it. The basis for the 
operation in question, Dr. Abbe said, was the fact that 
sensory conduction is isolated in the posterior root, 
which is easily operated upon withiu the dura. Ex- 
periments recently made by Singer, Ilorsley aud others 
to study the ascending degeneration after this section 
in monkeys showed that a speedy and complete degen- 
eration backward into the cord resulted from it. This 
would give the desired destruction of an inflamed or 



Vol.. CXX1II, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



87 



diseased nerve to its very ultimate fibres. In liis two 
cases there had remained all the anaesthesia obtained 
at the operation. Pain, however, had apparently re- 
covered, though much milder. There was often simu- 
lated pain in those who had acquired the morphine 
habit ; but in these two cases he believed it to be genuine. 
I lis conviction was that if all five roots had been cut 
the chances of recurrence would have been less. 

In conclusion, he said that while we were not war- 
ranted in taking a sanguinary view of the results of 
operation, yet surgery, with its possibilities ever 
looming up, ought not to occupy the ultra-conserva- 
tive ground of the past iu this field. The scope of 
operative work might never be a large one ; but it 
would probably not be as small as heretofore. 

Dr. John A. Wyktii said that he had been struck 
with the fact that in all the traumatic cases the seat of 
trouble was in the vicinity of the eleventh dorsal ver- 
tebra!, and that this was also true of two traumatic 
cases of his own. In the surgery of the spine he would 
suggest the following classification : In the first of two 
divisions he would place all cases of compression by 
bone, dividing these into classes ; first, those in which 
the compression was gradual, as iu Pott's disease, and, 
second, those in which there was compression and more 
or less destruction of the cord from sudden violence. 
In the second division he would place the cases of 
compression by tumors, dividing the latter into intra- 
dural and extra-dural tumors. In our present state of 
knowledge he believed the cases where there was de- 
struction of a portion of the cord were practically in- 
curable ; and this seemed likely to continue to be the 
case, unless it should become possible to remove the 
body of a vertebra, and thus enable the surgeon to 
bring together the healthy portions of the cord situated 
above and below the part that was destroyed. This 
was an operation, however, which he should not care to 
undertake or to witness at the present time. As to 
tumors of the cord, those which were intra-dural were 
naturally more dangerous than those outside the cord, 
and their removal afforded smaller chances of a favor- 
able result. 

He then gave an account of the two cases of fracture 
on which he had himself operated. In the first there was 
complete recovery, notwithstanding the fact that the 
patient had been paralyzed for more than two years 
previously. In the second case the cord was found to 
be somewhat flattened at the seat of trouble. There 
was considerable inflammatory lymph biuding the cord 
very firmly to the dura; and the adhesions between 
the cord and the dura were broken up with the finger. 
The injury had been received on the 16th of September 
last, and the operation was performed seventeen days 
ago. As a result of the operation sensation was imme- 
diately recovered down the entire lower extremities. 
Motion was also restored to the two great toes, but up 
to the present time the paralysis of motion had been 
relieved only to this extent. From his own observa- 
tion and reading he could not doubt but that in many 
cases of compression, and especially those of traumatic 
origin, the patients could be restored to usefulness by 
means of operative interference. 

Dr. A. P. Gerster said that an obstacle to the 
restoration of function in cases in which the spinal 
marrow was divided was the area of cicatricial tissue 
lying between the separated ends. He did not know 
whether or not experiments had been made on animals 
to find out whether, if the divided ends could be united 



the function would reappear ; but, from the experience 
met with in the case of divided nerves, it seemed pro- 
bable that it would. The matter was certainly worthy 
of investigation, and even desperate operative meas- 
ures he thought were justifiable in such cases, on 
account of their hopeless character. The technical 
difficulties of bringing together the divided ends of the 
cord could no doubt he overcome by practising the pro- 
cedure on the cadaver. Furthermore, he did not see 
why the extreme measure referred to by Dr. Wyeth, 
of removing an entire vertebra, should not be resorted 
to under certain conditions. If he thought such an 
operation would enable him to restore the functions of 
the lower portion of the cord he would not hesitate to 
perform it, provided he should first have demonstrated 
its practicability by experiment. He would not think 
of undertaking it, however, until it had been shown 
upon animals that such a restoration of function was 
possible by the uniting of the severed ends of the cord. 

His personal experience in spinal surgery had not 
been extensive. Eleven years ago he had had at the 
German Hospital a case of new growth involving five 
of the vertebra; and causing paraplegia. It had origi- 
nally, no doubt, been sarcomatous in character, and 
when seen by him it had become largely infiltrating. 
He succeeded in removing the greater portion of the 
mass, and in doing this he had to scrape some of it 
from the dura. The latter had become softened, and 
it gave way at some points; allowing a considerable 
amount of cerebro-spinal fluid to escape. The imme- 
diate results of the operation were very satisfactory, 
sensation and motion in the paralyzed extremities both 
becoming much improved. Later, however, a relapse 
occurred, and the case terminated fatally. 

A second case of his had a more favorable result. 
It was one of vertebral tuberculosis of longstanding in 
a lad fourteen years of age, who was admitted to the 
Mt. Sinai Hospital in December, 1888. In May, 1889, 
rapidly increasing paraplegia set in, and within a fort- 
night it was complete. On May 24th it was decided 
to explore the local state of affairs. The lamina; of the 
sixth and seventh dorsal vertebrae were removed by the 
chisel and mallet, and an extensive extra and sub-dural 
abscess was evacuated. Widespread confluent caseation 
of the soft tissues adjoining the intravertebral focus was 
found, and in the caseous masses were imbedded the 
roots of the nerves on both sides. The transverse pro- 
cesses of fifth, sixth, seventh and eighth thoracic ver- 
tebra? on the right, and those of the fifth, sixth and 
seventh on the left, were found carious and partially 
necrosed, and the pertinent costo-vertebral joints de- 
stroyed. Consequently, these transverse processes were 
removed, as well as the heads of the respective ribs. 
The bodies of the sixth and seventh vertebra; were also 
much disintegrated, and their broken-down constituents 
were gouged away. No immediate improvement in the 
paralytic symptoms resulted from the operation ; but in 
the following August the power and functions of the 
lower extremities were re-established ; and this restora- 
tion took place in the short space of ten days. By 
massage, faradism, and active movements the muscu- 
lar power was so enhanced that by October the patient 
was able to support himself without external aid ; while 
in December, when he left the hospital, he could walk 
very well and had only a slightly-discharging sinus in 
the back. 

Dr. Morris said that ascending and descending de- 
generation followed division of the cord ; but it seemed 



88 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 24, 1890. 



to him that if, in case of its accidental severance, we 
could get the two ends of the cord together within a 
few hours, we might hope for a restoration of function. 
The ends, it was found after division, did not retract 
very far, for the reason that the spinal nerves are 
given off at short intervals. It seemed probable that 
it would be necessary to remove a vertebra ; and in 
attempting this the most troublesome feature encoun- 
tered would be the crowding together of the spinal 
nerves. The dauger of such a procedure need scarcely 
be taken into consideration since the cases in which 
it might be thought of were of such a very desperate 
character. He had at present under his care a boy 
eleven years of age who had been shot with a twenty- 
two bullet in the line of the tenth dorsal vertebra, with 
the effect of producing paraplegia. He first saw the 
patient seven days after the injury, and he immediately 
cut down and opened the spinal canal. He removed 
an articular process which was found pressing upon the 
cord ; and this was at once followed by improvement 
in both sensation and motion. In the right leg the 
recovery was now almost complete, but in the left the 
paralysis still continued to a very considerable extent. 
He was not able to find the bullet which had, no doubt, 
lodged somewhere in the spinal cord. 

Dr. R. H. Sayre urged immediate operative inter- 
ference in recent traumatic cases, but thought there 
were many cases of paraplegia resulting from Pott's 
disease in which a cure could be effected without 
resorting to operation. Cases which did not yield to 
systematic treatment directed to Pott's disease within 
twelve months, however, he said might very properly 
be looked upon as suitable cases for operation. 

Dr. Sachs said that up to the present time the 
results that had been obtained in spinal surgery were 
not especially gratifying. As a neurologist he thought 
that surgeons should select their cases for operation 
with more care than they had hitherto done. With 
Dr. Sayre he believed that recent cases presented the 
best opportunities for operative interference. If the 
cord were separated into parts, however, there was in 
his opinion not much hope of accomplishing anything. 
In cases in which the symptoms had become less 
marked than they were at first, as was the case in one 
of Dr. Wyeth's patients, there was a much better 
chance for success, since the amelioration indicated 
that there had not been a total destruction of tissue. 
Dr. Abbe, he thought, was deserving of great credit 
for demonstrating that such good results could be 
obtained in tuberculous cases as were presented in the 
patient he had exhibited. Formerly the opinion had 
been that no operation ought to be undertaken in 
cases of this character. He had been a little puzzled 
to understand why in some of the cases reported by 
surgeons so many laminae had been removed. As a 
rule, he believed this was entirely unnecessary, since, 
if proper care were observed in diagnosis, the lesion 
could ordinarily be located with very great accuracy. 
Operations for the relief of neuralgic trouble seemed 
to him to be the most objectionable in the whole 
range of spinal surgery. Judging from the results 
obtained by Dr. Abbe in the two cases he had reported, 
no improvement whatever was to be expected from 
them, and, in any event, this was certainly a very 
radical method of attacking neuralgias. It was to be 
remembered that pain was not the only symptom that 
was likely to result from trouble involving the poste- 
rior spinal roots. Vaso-motor disturbances especially. 



as well as neuralgia, would be apt to follow. As 
these two cases showed, unless we had good reason to 
infer the exisience of organic disease of the posterior 
spinal roots, it would not be well to interfere in this 
way. 

Dr. Abbe said, in regard to neuralgia, that no sane 
man would think of operating in ordinary cases. In 
the two patients upon whom he had operated, how- 
ever, the trouble was so exceedingly aggravated and 
so utterly unamenable to all other remedial measures 
that the procedure seemed to him entirely justifiable 
as a last resort. That such operations might be at- 
tended with success was shown by a case in England 
reported by Bennett. It was one of sciatic neuralgia, 
and though the patient unfortunately died of apoplexy 
twelve days after the operation, from the time of the 
latter there was complete freedom from the pain 
which before had been so constant and so excruciat- 
ing. In his own two cases he wished it to be dis- 
tinctly understood that the character of the pain ex- 
perienced was entirely altered after the operation. 
In both patients he believed there had been a hysteri- 
cal element, although he had tried to eliminate this as 
far as possible. Both were also still taking morphia 
largely, and such cases could not be depended upon. 
Moreover, it so happened that both of these men were 
trying to get pensions on the ground of disability 
from the pain. While, therefore, he really believed 
them to be genuine sufferers, he was not at all sure 
about the matter. In fractures of the spine he thought 
the operation should very rarely be done. He was 
not positive, however, that restoration of innervation 
to the lower segment of the cord could not be success- 
fully accomplished after further experiments had been 
made upon animals. But to bring the divided parts 
of the cord directly together again he believed could 
only be accomplished by removing one of the vertebrae, 
and this did not seem possible to him without destroy- 
ing the patient's life. 



AMERICAN NEUROLOGICAL ASSOCIATION. 1 

^ ON INGRAVESCENT APOPLEXY. 

Dr. C. L. Dana read a paper with this title. He 
said that there were three sets of intra cranial blood- 
vessels, those in the dura, those in the pia mater, and 
those in the substauce of the brain. We had corre- 
spondingly three types of iutra-cranial haemorrhage. 
The central haemorrhages were far the most common, 
and presented a tolerably uniform clinical type. There 
was one form, however, which had seemed to have 
escaped critical attention, though it could not be exces- 
sively rare. In 1876, Dr. Broadbent had reported six 
cases of what he had termed " ingravescent apoplexy." 
In 1889, M. P. Prusch, of Montpellier, had also re- 
ported a case of the same character. The writer had 
met two cases presenting the general clinical charac- 
ters of ingravescent apoplexy, but was able to make 
an autopsy upon only one, of which the data was as fol- 
lows : A woman was brought to the hospital May 1st, 
without any history. She was in a stupid condition 
but not unconscious, and she was at first thought to be 
intoxicated. Examination showed, however, some 
hemianalgesia of the left side and slight hemiplegia of 
the same side. The right pupil was slightly contracted, 
temperature normal, pulse tense. Next day the pa- 

1 Report of tlie Sixteenth Annual Meeting, held at Philadelphia, 
June 4-6, 1890. Concluded froui page 63 of the Journal. 



Vol. CXXIII, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



89 



tient's mind was clearer; she answered questions and 
recognized those about her. But the hemiplegia was 
very much worse, and the analgesia no hotter. Toward 
night she became more stupid and finally comatose; 
oedema of the lungs developed. No contractures of 
the paralyzed side were noted. The temperature rose 
and the patient died next day, May 3d. 

At the autopsy the brain was found congested. 
Pressure over the supramarginal gyrus showed that 
there was a softened place beneath it. The brain was 
placed in boroglycerine and alcohol, and opened later 
by vertical section. There showed a clot in the lateral 
ventricle and some blood in the third ventricle. Be- 
neath the supramarginal gyrus was a large haemorrhagic 
focus about one inch an a half in diameter. This ex- 
tended forward and downward cleaving the external 
capsule. The hemorrhage had finally extended down- 
ward and inward, and broken into the lateral ventricle. 
Prusch had attempted, on the slender basis of seven 
cases, to erect " ingravescent," or, as he called it " pro- 
gressive," apoplexy into a distinct type. This seemed 
to the author to be somewhat premature. The history 
of his case was not exactly like those of Broadbent's 
in respect to retention of consciousness ; and the hemi- 
plegia was relatively less marked. Yet anatomically 
it was one of the "cleaving" haemorrhages due to 
rupture of a posterior branch of a lenticular artery, 
and running the same course as was described by 
Broadbent. The hemiamesthesia seemed to the author 
to be a very distinctive point. Practically the ques- 
tion came up as to whether in such cases trephining 
would be justifiable. In general, the idea of trephin- 
ing for non-traumatic haemorrhage was not to be enter- 
tained at all. But in ingravescent apoplexy it deserved 
consideration because here the haemorrhage was acces- 
sible, and because, unless some relief was given, it 
would surely break into the lateral ventricle and kill 
the patient. In all the reported cases, also, the patients 
were not old, were not syphilitic, and presumably had 
not extensively diseased arteries. In reaching haemor- 
rhages in these cases, the best place to trephine would 
be a little below and in front of the parietal eminence. 
The surgeon should then explore downward aud for- 
ward, care being taken not to injure the terminal 
branches of the Sylvian artery, which were in this 
neighborhood. In cases of " ingravescent " apoplexy, 
surgical interference, if undertaken, must be before 
the blood broke into the ventricles. This could be 
told by the sudden increase in the severity of the 
symptoms, and, if the blood was poured in rapidly, by 
contractures on the paralyzed side. The temperature 
changes were believed to be the same in the ingraves- 
cent as in ordinary apoplexy. 

Dr. Mills had seen a number of such cases. The 
results of his experiments had led him to think that the 
trephining, if done at all, should be several inches back 
from the temporal lobe, along the junction of the 
second and third temporal convolutions. He had known 
of patients with intra-ventricular haemorrhage recover- 
ing independent of the question of trephining. 

Dr. W. Sinkler said Dr. Dana had referred to the 
question of temperature. He had recently had a patient 
die from enormous haemorrhage into the ventricle and 
the temperature at death was 108°. 

Dr. Webber questioned the utility of trephining in 
those cases in which the history was rupture. 

Dr. Mills said the advantage of trephining was that 
it gave the patients a lease of two or three weeks as 



the breaking into the ventricles did not take place 
until late. By trephining and finding the bleeding 
point, there was perhaps a chance of controlling it. 

Dr. Dana said that trephining was purely empirical, 
and he could not say whether it was good or not. 

PONS LESIONS IN THEIR RELATION TO ASSOCIATED 
EYE MOVEMENT PARALYSIS. 

Dr. SPITZKA presented this paper by title, accom- 
panied by the demonstration of a specimen of a minute 
focal lesion of the dorso-caudal part of the pons, uni- 
laterally situated in and near the abducens nidus. In 
connection therewith, Dr. Putnam mentioned one of 
similar location to Dr. Spitzka's, in that the presuma- 
ble lesion must have occupied the same position. 

A CONTRIBUTION TO THE PATHOLOGY OF THE SOLI- 
TARY TUBERCLE OF THE SPINAL CORD, 

by Dr. Heutkr. 

The paper consisted of a report on the clinical his- 
tory aud pathological anatomy of three hitherto un- 
published cases of solitary tubercle of the cord, and of 
a brief analysis of the clinical and pathological features 
of the condition based on these cases, and in those 
which had been collected from the literature on the 
subject. It was believed that the clinical history of 
solitary tubercle of the cord could be more accurately 
written than heretofore, with the help of the facts that 
had been recorded in the given cases. The uniformity 
of the symptoms in different cases, especially as regarded 
their course, the rapidity with which the usually unilat- 
eral symptoms became bilateral, the comparative in- 
significance of the irritative phenomena, and the fre- 
quency with which the signs of tubercular disease in 
other organs existed, were characters of solitary tuber- 
cle of the cord which might help in this distinction, 
both from tumor of the membranes and from other 
varieties of tumor of the cord. 

Dr. Sachs said it was some years since his paper 
on this subject was written. At that time he had 
thought that the very slow development, the strictly 
unilateral symptoms aud subsequent spread of the 
disease involving both halves, would constitute a basis 
for diagnosis of tumor of the cord. Now the point 
came up with regard to the possibility of distinguish- 
ing between extra- and intra-dural tumors. 

DEMONSTRATION OF SOME SPECIAL ANATOMICAL 
CHARACTERISTICS IN THE BRAIN OF A DISTIN- 
GUISHED SCIENTIST. 

Dr. B. J. Wilder presented the brain of the late 
Mr. Chauncy Wright, and demonstrated to the Asso- 
ciation what he deemed striking anatomical points. 
One peculiarity specially dwelt upon was the existence 
of a very simple insula, instead of a complex one. 
Then the inhibition of the fissure of Rolando by an 
isthmus was so rare as to call for attention. Then in 
contra-distinction to the condition in other brains it 
would be seen that the central fissure above that point 
was shallow. The speaker urged his hearers to aid 
in every way possible the further investigations of 
comparative anatomical study in this field. To suc- 
cessfully effect this it was necessary to secure young 
human and apes' brains in every stage of development. 

TUMOR OF THE QUADRIGEMINAL REGION WITH SPE- 
CIAL REFERENCE TO OCULAR SYMPTOMS. 

Dr. B. Sachs read a paper with this title. He had 
been fortunate enough to obtain two autopsies, during 
the past year, which bore upon this question, and also 



90 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 24, 1890. 



several cases which were subjected to careful clinical 
examination. His first case was one of unusually 
severe tuberculosis cerebri. The main points of the 
history, which he had been able to complete, through 
the kindness of several colleagues, were these : E. L., 
aged three years, when first seen she had double ptosis, 
but no other ocular paralysis was observed. She was 
dull and listless, and had a pulse that ranged from 
145 to 160, but with normal temperature. The 
mother had noticed a change in the child's disposition 
since an attack of measles nine mouths previously. 
The child did not care to play, but preferred to sit 
quietly in a chair all day long. She staggered in 
walking and occasionally fell. She had no epileptical 
attacks, and had vomited but once. Knee-jerk was 
absent. The right hand was weaker than the left. 
No anaesthesia or ataxia. There was paresis of both 
lavator pulpetrani, the pupils being half covered. No 
nystagmus. Pupils were equal, moderately dilated, 
and reacted well to light and accommodation. Decem- 
ber 28, 1888, the patient had come under Dr. Sachs' 
care. The condition at that time had showed great 
changes. Examination disclosed double and almost 
complete ptosis. There was no upward or downward 
movement of either eye. Both external recti muscles 
were thrown into clonic spastic condition when the 
attempt was made to use them. The interni were 
capable of very slight movement, but all the other 
ocular muscles were completely paralyzed. The ac- 
commodative reflexes were still distinct, aud there 
was slight contractility to light. There was also slight 
left facial paresis. The vision was very much im- 
paired. Although in a semi stupor, the child could 
be made to walk, and then exhibited most distinct 
cerebellar staggering, walking with a broad base, and 
almost falling to the right side. The oculist reported 
plaques of choroidal atrophy below the macula of 
left eye. The reflexes were exaggerated, aud there 
was occipital headache. The diagnosis of tumor of the 
corpora quadrigemiua was given. The tumor was 
supposed to be associated with a general tubercular 
meningitis. The child grew rapidly worse, and after 
passing through several convulsive seizures, becoming 
blind, and finally developing left hemiplegia, died 
February 4, 1889. Autopsy showed the dura adherent 
to the skull aud it had to be removed with the calva- 
rium. The quantity of the sub dural fluid was slightly 
increased. A solitary tubercle was at once discovered 
near the right lateral sinus, pressing into the lateral 
edge of the cerebellum and producing thrombosis of 
the lateral sinus. Other tubercles with large areas 
of softened tissue were found in the cerebellum. 
Deep examination of the brain showed the hemi- 
spheres to be healthy, with the exception of the small 
tubercular deposits along the paths of the blood-ves- 
sels. The cerebellum was the seat of the most pro- 
found changes. The base presented several unusual 
conditions. There was great thickening of the pia 
with small tubercular deposits between the corpora 
mamillaria and optic chiasm, and in the interpeduncu- 
lar space. The thickening at this point was so great 
that both third nerves instead of lying across the 
crura, after removal of the brain, pointed backward, 
and the right, the sixth, was twisted out of its position. 
Section of the brain showed the tumor to occupy 
almost the centre of the tegmental division of the crus 
and had left a very small portion of the corpora quad- 
rigetnina and the. brachia intact. The occipital head- 1 



aches and the cerebellar staggering were the only 
symptoms which could be ascribed to the large tuber- 
bercles in the cerebellum, though both these symp- 
toms might be due to the lesion of the quadrigeminal 
region. It was probable that the sixth and seventh 
nerve nuclei were responsible for the symptoms point- 
ing to lesions of those nerves, or that the basilar men- 
ingitis was at fault. Certain it was that the latter 
condition was late iu developing, as for months the 
symptoms had been distinctly nuclear. In spite of 
the manifold morbid conditions, it was most remarka- 
ble that the ciliary muscles and the sphincter iridis 
had remained exempt during the entire period of obser- 
vation. Considering the compactness of all cerebral 
structures in the crura, it would be supposed that 
there could be no difficulty in making a differential 
diagnosis between cases of tumor in this region, and a 
chronic imflammatory process. 

CRUS LESION. 

This was the title of a second paper by Dr. Sachs. 
Crus lesions were rarer than many other cerebral 
lesions, but their symptoms were well-marked. The 
case under consideration had some special interest, 
however, iu connection with post-hemiplegic distur- 
bances of motion and from this point of view, the 
results of the post-mortem examination were worthy 
of consideration. Seven years ago the patient, a 
woman, about fifty years of age, had had a dizzy at- 
tack one morning, aud had found her vision rather 
blurred. There was a recurrence of the attack in 
fifteen minutes. There was no unconsciousness nor 
difficulty with speech, but when the patient attempted 
to walk she found she could not with ease. By 
morniug she had almost complete left hemiplegia, 
she could not open either eye. At that time speech 
was heavy and indistinct, but from this she had recov- 
ered in three weeks. Hearing, taste and smell were 
altogether normal. The hemiplegia was never recov- 
ered from, the patient became somewhat unruly and 
demented, and was finally taken to the Montefiore 
Home where she had remained for many years. A 
few further details of the patient's chronic condition 
were elicited in examination. There had been no 
history of syphilis, but there was very marked ather- 
oma of the peripheral arteries. Iu addition to the 
left hemiplegia, the patient had suffered amputation 
of the right leg above the ankle, for old necrosis of 
the tibia, fully six years before. There was rigidity 
of the left leg and increased knee-jerks of both sides. 
The wrist reflex was decidedly increased on the par- 
alyzed side, but the left upper extremity was subject 
to the wildest ataxic movements. This would go on 
until the arm dropped from exhaustion, when it would 
remain quiet until aroused again by an effort to use 
the hand. She became extremely emotional, took 
very little nourishment and finally died. The diagnosis 
of crus lesion of the right side, probably softened from 
thrombosis, was made, which the autopsy confirmed. 

ON THE GERM OF A COMMUNICABLE DISEASE DE- 
RIVED FROM A DOG, ALLEGED TO HAVE DIED 
OF RABIES, WHICH RETAINS RABIC CHARACTERS. 

Dr. Richard Mollknhauicr exhibited some mi- 
croscopic specimens taken from a dog which he had 
succeeded in rendering rabid bj inoculation. The 
germ was a bacillus whose various growth-stages 
presented a uniform type. 



Vol. CXXnt, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



91 



A CASE OF INSULA R SCLEROSIS IN WHICH AN AT- 
TACK OF CEREBRAL HEMORRHAGE ARRESTED 
THE TREMOR ON THE 1 1 EM I PL EG IC SIDE. 

Dr. Wharton Sinkler related the history of this 
case. The patient, a man aged sixty-four years, had 
always enjoyed good health until about ten years ago 
when he began to notice tremor in both hands, but 
worse in the left. In 1889 he had experienced an 
attack of left hemiplegia without loss of consciousness. 
Since that attack there had been no tremor on the 
left side, but a coarse tremor on the right side still 
persisted. The patient's appetite and general health 
had remained good. The hemiplegia continued about 
the same with no further involvement of the tremor. 

remarks on therapeutics as applied to ner- 
vous DISORDERS. 

Dr. W. R. Birds all read a paper with this title. 
Early diagnosis he regarded as the most important 
factor for therapeutic success in diseases of the ner- 
vous system, as it frequently enabled the physician to 
check the course of a disease where marked disability 
had not yet resulted. Hygienic measures were con- 
sidered of prime importance and pharmaceutical rem- 
edies as valuable accessories in the treatment of these 
diseases. All relation between storage and expendi- 
ture must be readjusted to the disturbance in equilib- 
rium, and the aim of therapeutics consisted in bring- 
ing about such a readjustment. The modern craze 
for so-calied physical culture, the author believed was 
bringing forth dangers as great as those it was sought 
to remedy, through over-training, improper training, 
training for brain workers, which fatigued rather than 
rested the brain, together with other faulty methods. 
Hydrotherapy he considered was much neglected, 
and electrotherapy overestimated. Next to hygiene 
cutaneous irritation was decidedly the most impor- 
tant therapeutic measure possessed by the neurologist. 
Surgical interference and the drugs usually employed 
by the neurologist were then briefly referred to. 

Dr. W. Sinkler believed in the use of drugs in 
nervous disorders. No doubt arsenic in chorea, hy- 
oscyamine or hyoscine in various tremors, the iodides 
and antisyphilitic remedies in specific diseases of the 
nervous system were all of value. He wished to put 
himself on record as not being a pessimist or nihilist. 

Dr. Brush said he wanted to accentuate what Dr. 
Birdsall had said as to the management of cases of 
nervous diseases. A great many could be better 
treated by other means than drugs. He should some 
day present some cases of insanity from drug poison- 
ing. Once he used to try everything that came along, 
but now he made less and less use of drugs. 

Dr. L. C. Gray said he was a believer in the effi- 
cacy of properly directed therapeutic measures in 
combination with everything else in the treatment of 
nervous disorders. Chorea in all its minor forms, 
neuralgias, functional nervous disorders, subacute or 
acute mental troubles, except acute mauia, were all 
amenable to judicious therapeutical endeavor on the 
part of the neurologist. 

The officers elected for the ensuing year were, 
President, Dr. Wharton Sinkler of Philadelphia ; 
Vice-Presidents, Dr. C. L. Dana of New York and 
Dr. S. G. Webber of Boston ; Secretary and Treas- 
urer, Dr. G. M. Hammond of New York ; Councillors, 
Dr. G. L. Walton of Boston and Dr. L. C. Gray of 
New York. 



THE BOSTON 

jHeDical anD Surgical Journal. 

Thursday, July 24, 1890. 



A Journal of Medicine, Surgery . and Allied Sciences, published at 
Boston, weekly, by the undersigned . 

SuiiSCUij-riON TERMS : $5.(I0 per year, in advance, pottage paid, 
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All com munications for the Editor, and all books for review, slum Id 
be addressed to the Editor of the Boston Medical and Surgical Journal, 
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should be addressed to the undersigned. 

Remittances should be made by money-order, draft or registered 
letter, payable to 

DAMRELL & UPHAM, 
283 Washington Street, Boston, Mass. 



CARDIAC DYSPNCEA. 



When we consider the frequent coincidence of car- 
diac lesions with dyspnoea, we cannot regard it as sur- 
prising that in the infancy of pathological anatomy 
Rostan, noticing in a large number of aged patients at 
the Salpetriere recorded as asthmatic, definite lesions 
of the heart and aorta, should have concluded that 
asthma, as an idiopathic malady, does not exist, being 
always symptomatic of diseases of the circulatory 
organs. 

When we inquire into the conditions of cardiac dysp- 
noea, we find them to be : mitral stenosis and insuffi- 
ciency, myocarditis and fatty degeneration of the 
heart-muscle, dilatation of the ventricles and aorta, 
from whatever cause, and uncompensated lesions of 
the valves of the aorta and pulmonary artery. 

In the case of most of the above causes, the modus 
agendi is very simple ; the dyspnoea is of mechanical 
origin, being the result of pulmonary stasis ; the heart 
is unable to clear the capillaries in the sphere of the 
lesser circulation. 

Most persons affected with mitral disease are short- 
breathed ; when at rest they have little or no dyspnoea, 
but they immediately suffer for want of breath when 
they attempt any considerable exertion, as going up a 
flight of stairs, or ascending a hill. In the earliest 
stages of mitral insufficiency, the dyspnoea may be 
hardly noticed, except when the heart is severely 
taxed, as in the effort of running ; in advanced stages, 
the difficult breathing becomes permanent on account 
of the constant pulmonary engorgement. There is 
nothing asthmatic about this, for the essential charac- 
teristic of asthma is the intermittent and paroxysmal 
character of the dyspnoea. 

The difficult breathing attending aortic-regurgitant 
disease, aortitis, dilatation of the heart-cavities and 
aorta, fatty degeneration, etc., is generally paroxysmal 
in its nature, and the attacks come on in the night 
time rather than in the day. The explanation given by 
Professor See was formerly regarded as satisfactory : 
"The blood-stasis in the lungs, which is the first cause 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 24, 1890. 



of the oppression, manifests itself generally in the 
night time, because it is favored by declivity, that is, 
by the dorsal decubitus ; to this first cause are added 
others which contribute much toward provoking the 
explosion of those attacks of respiratory distress which 
often present a formidable intensity ; these purely 
mechanical causes are : distention of the stomach, the 
forcing upward of the diaphragm, which notably dimin- 
ish the respiratory area already insufficient for haema- 
tosis. Add, as accessory causes, bronchial catarrh and 
frequent concomitant emphysema, and you have the 
entire etiology of paroxysmal dyspnoea linked to affec- 
tions of the heart." 1 

The dyspnoea due to dilatation of the heart, accord- 
ing to Professor See, is almost always continuous, 
though there are paroxysmal exacerbations, and that 
due to fatty degeneration is sui generis, " presenting 
sometimes real paroxysms of distress and suffocation 
at the same time that careful examination of the lungs 
does not reveal any morbid signs ; there is not the 
least acceleration of the breathing, or any apparent 
impediment to respiration." 

Irritation of the cardiac and respiratory plexuses of 
nerves, as Peter, Trousseau, etc., teach, has been be- 
lieved to have some share iu the respiratory distress, 
and magical relief conferred by a hypodermic injection 
of morphine or other calmative, before even the pul- 
monary congestion or oedema is mitigated, has been 
cited in confirmation of this doctrine. 

Henri Huchard has, of late, written much and lucidly 
on the paroyxsmal dyspnoea of aortic regurgitation and 
aortitis. The dyspnoea of aortitis is, like that of mitral 
disease, at the first a dyspnoea of effort, coming on 
during rapid walking, lifting, etc. ; it is paroxysmal 
and often intense, rarely spontaneous. Later on in 
the disease, the attacks come on in the night time, often 
reproducing themselves with great regularity, so that 
the patient is obliged to pass the night in his arm- 
chair. Huchard regards this "aortic pseudo-asthma" 
as due to arterial hypertension which " augments by the 
recumbent posture and under the influeuce of sleep, as 
also by walking, and under the influence of movement." 
The cause of the dyspnoea is " mechanical," as Profes- 
sor See taught, but not in the same sense as he taught, 
for in Huchard's view, we have to do with " peripheral 
resistances," and "spasm" of the blood-vessels. If, 
says Huchard, distention of the stomach has anything 
to do with the paroxysmal dyspnoea, abstinence from 
the evening meal or a very frugal repast ought to keep 
the patient free from his nocturnal attack ; this is, 
however, sure to come, whether he eat little or much. 

This dyspnoea, Huchard affirms, is also of toxic 
origin. Experiments like the following seem to de- 
monstrate this. He injects under the skin of a guinea- 
pig normal urine ; death ensues in several days. He 
injects the same quantity of urine from a woman 
affected with arterio-sclerosis of the heart and aorta, 
and the guinea-pig scarcely suffers any detriment. This 
proves, he says, that the blood of his patient was poisoned 

• Maladies du Coeur, etc., 1883, p. 30. 



by the products of disassimilation which the kidneys, 
already impermeable by the fact of the aortitis and a 
commencing arterio-sclerosis, could but incompletely 
eliminate. These views, he urges, are not simply 
theoretical, they are confirmed by practice. In fact, 
blood-letting, purgatives, nitrite of amyl, nitro-glycer- 
ine, etc., which depress arterial tension, contribute in 
large measure to diminish the intensity of the attacks. 
But nothing works so well as an exclusive milk diet, 
which acts marvellously in combating these attacks of 
aortic dyspnoea, often keeping them completely in 
abeyance. Now milk diet, according to Huchard, acts 
in two ways and meets two indications : first, by the 
abundant diuresis which it provokes, the milk dimin- 
ishes the arterial tension and promptly eliminates the 
toxic principles contained in the blood ; then it acts 
by virtue of its very harmlessness and because it does 
not launch into the circulator}' current, like other 
aliments, and meat in particular, materials which, not 
being completely eliminated, become rapidly toxic to 
the economy. 2 



MEDICAL NOTES. 

— The following dispatches have been received by 
the United States Secretary of State from H. R. New- 
berry, charge d'affaires at Madrid, under date of 
June 20-23, 1890: 

" Sir : — It is difficult to say just the exact condi- 
tion of things in the province of Valencia in regard to 
the cholera epidemic. This much is certain, that 120 
deaths have occurred in the province of Valencia from 
cholera morbus, or Asiatic cholera, as the doctors are 
about evenly divided as to which it is. The inhabi- 
tants, such as are financially able, are leaving the 
country, and the government is sending physicians and 
medical supplies to the district in trouble. From con- 
versation with my colleagues of the diplomatic corps, 
I am inclined to believe that the condition of affairs is 
not exaggerated, and that the disease is spreading 
gradually, as press dispatches keep reporting new 
cases, each time a little farther away from the original 
bed of disease. Three cases are unofficially reported 
iu Madrid. 

" At my own expense, I sent a man to the village 
of Puebla de Rugat, iu the valley of Albaida. He 
has returned, and reports a sad condition of things. 
Out of a population of 1,500 people in the valley, 
there have been 127 deaths; 800 have fled to neigh- 
boring villages, and those remaining are in dire desti- 
tution, without money and food, and 200 of them sick. 
The authorities of the province are doing all they can, 
but they have no disinfectants, few physicians, and, 
with the extreme heat and deplorable condition of 
sanitary arrangements, the situation cannot help but 
become dangerous. . . . 

"From private information, I know that there were 
61 deaths in the village of Puebla de Rugat for the 

2 Vide Huchard, Maladies du Cceur et des Vaisseaux, Paris, 1889. 
Also, La dyspn^e chez les cardiaques, in Seniaiue Medicale, April 13, 
1890, p. 125. 



Vol. CXXril, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



93 



twenty-four hours ending midnight June 19th, and 
16 at Montichelvo, a village of 850 people. The 
Academy of Medicine has issued a bulletin stating 
that the disease is Asiatic cholera. . . . 

." The authorities have prohibited anti-cholera vac- 
cinations, as practiced by Dr. Ferran's system. The 
district of Gandia is prohibited from exporting fruit 
and vegetables." 

— Manor, a town of five hundred inhabitants in 
Westmoreland County, Pa., is striken with a malignant 
type of typhoid fever. There are over two hundred 
cases in the town and the deaths have been four a day 
for the past two weeks. The cause of the scourge is 
attributed to the impurity of the water. 

— Dr. John A. Wyeth, of New York, has promised 
to deliver the address before the Mississippi Valley 
Medical Association, at Louisville, Ky., October 8, 
1890; and Dr. Frank Woodbury, of Philadelphia, 
will read a paper. A number of gentlemen promi- 
nent in medicine in the Mississippi Valley have prom- 
ised to read papers and discuss subjects. Among these 
are Drs. Reamy and Whittaker of Cincinnati, Sutton 
of Pittsburgh, Corlett and Scott of Cleveland, Love 
of St. Louis, King of Kansas City, and many others. 

— In a lecture on Syphilis, delivered before the 
Royal Academy of Medicine, Dublin, Mr. H. Fitz- 
gibbon is reported to have read a quotation from Lan- 
cereaux's work on " Syphilis in Ancient Times and in 
the Middle Ages," found in Chinese medical writings so 
far back as 2637 B. C. This describes, it is said, what 
one cannot fail to recognize as a hard chancre, fol- 
lowed by all the phenomena which mark the course of 
a neglected case of syphilis. Commenting on this 
statement, the Chinese Medical Missionary Journal 
says this date seems to be somewhat wild. Wylie 
states that the oldest medical treatise extant is proba- 
bly the " Hwang te soo wan," which there is reason 
to believe, he says, to have been written several cen- 
turies before Christ. 

NEW YORK. 

— At two o'clock on July 15th, the first water from 
the new Croton Aqueduct was permitted to enter the 
Central Park Reservoir. It was expected that the 
Mayor would be present, and turn the regulator at the 
gate-house ; but he arrived a little too late to perform 
that function. After that the water flowed in from four 
small sluice-ways at the rate of 1,500,000 gallons per 
hour, in addition to the supply coming from the old 
aqueduct. At the meeting of the Aqueduct Commis- 
sioners on that day, the following resolution was 
adopted : . 

" Resolved, That, as our citizens enjoy to-day by the 
utilization of the new aqueduct, for the first time, the 
benefits of an undertaking which stands an unparal- 
lelled monument to engineering skill, and which in 
every way contributes to our city's health and welfare, 
the members of this commission warmly congratulate 
the public of the city of New York upon the virtual 



fruition of an enterprise of such incalculable magni- 
tude and merit." 

In addition to the four pipes to Central Park, there 
are four other pipes, of the same capacity, from the 
135th Street gate-house to various distributing points 
in the city ; but water lias not yet been let into them. 
Since the fresh supply of water is drawn from the 
same source as the old Croton Aqueduct, it will, of 
course, be understood that the completion of the new 
aqueduct does not imply an increased water-supply, 
but the means of bringing to the city more of the 
existing supply, and also the increased supply when 
new storage reservoirs now in contemplation shall 
have been finished and filled with water. The first of 
these new reservoirs will not be ready for storage until 
next spring. The most important of the new reser- 
voirs is to be the one formed by the construction of the 
great Quaker Bridge Dam, and this has not yet been 
commenced. 

— It has been decided not to contest the will of 
Mr. William J. Syms, which leaves $350,000 to build 
and equip the fine operating theatre at Roosevelt 
Hospital. The will was probated last summer, and in 
April last a sister of the deceased began proceedings 
for the revocation of the will, on the ground that her 
brother was of unsound mind when he made it, and 
that he was under undue influence. The revocation 
proceeding has been abandoned, and there is now no 
obstacle to the carrying out of the will. 

— In the Carroll case, in Brooklyn, in which the 
patient was supposed to have been poisoned by a dose 
of crystalline hyoscyamine put up by a druggist's 
clerk, in mistake for amorphous hyoscyamine, and in 
which the body was embalmed by an undertaker be- 
fore an autopsy was made, the coroner's jury has ren- 
dered a verdict that the deceased came to his death 
from natural causes. The drug clerk was censured, 
however, for carelessness in filling the hyoscyamine 
prescription. At the inquest, Drs. Gustav Miiller and 
R. G. Eccles were called as experts ; and they testi- 
fied that they had never heard or read of a case of 
hyoscyamine poisoning, and that the effect could not 
have been fatal whether the druggist had put up the 
crystalline or amorphous form of the drug. 

— For some time past complaints have been made 
to Health Commissioner Griffin, of Brooklyn, about 
the persistence with which mothers of very young chil- 
dren have been besieged by manufacturers of infant 
foods and kindred preparations. Most of the com- 
plainants, it is said, have been physicians, some of 
whom said that they had been charged by their pa- 
tients with betraying their circumstances to manufac- 
turers. The physicians were, in consequence, led to 
suspect that some one connected with the Bureau of 
Vital Statistics was the guilty party ; and an investi- 
gation by Commissioner Griffin has resulted in the dis- 
covery that one of the clerks in this department had 
been communicating the name and address of every 
woman who became a mother, and had been paid by 



94 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 24, 1890. 



the manufacturers referred to for the information thus 
conveyed. The practice was, of course, at once put a 
stop to. 



WOMEN'S SCHOLASTIC HONORS. 

Miss Fawcett's triumph in the mathematical tripos 
puts the crown on a long series of successes by women 
students at Cambridge. There have now been women 
" seniors " in all the important triposes (except law). 
Here is the list as we find it in Science : — Moral 
Science tripos: in 1880, Miss Jones was bracketed 
senior ; in 1881, Miss Moberly was senior ; and so in 
1884 was Miss Hughes. Historical tripos : in 18o6 
Miss Rolleston (daughter of the late Oxford professor 
of zoology) was bracketed senior, and in 1887, Miss 
Blanche Paul was similarly placed. Mediaeval and 
modern language tripos : here there have been four lady 
seniors. In 1886, two women and no men were placed 
in the first class. The women, who were placed in 
alphabetical order, were Miss Chamberlain and Miss 
Skeat (daughter of Professor Skeat). In 1887, Miss 
Harvey was senior ; and 1888, Miss Tuke (whose 
father is well-known in connection with schemes of 
Irish emigration). Finally, there are the successes 
of Miss Ramsay in the classical tripos (1887), and of 
Miss Fawcett in the mathematical (1890). Of these 
eleven lady seniors, two came from Girtou (Miss Jones 
and Miss Ramsay), the rest from Newnham. It is 
often asked what becomes of women students when 
they leave college. A few particulars about some of 
these lady seniors may therefore be added. Miss 
Ramsay is now Mrs. Montague Butler, the wife of the 
master of Trinity ; Miss Moberly is head mistress of 
the Tunbridge Wells High School for Girls ; Miss 
Hughes is head of a training-college at Cambridge ; 
Miss Chamberlain is Instructor in German at Bryn 
Mawr College, Philadelphia; and Miss Jones is Moral 
Science Lecturer at Girton. Promptly to repair the 
apparent neglect of legal studies came the news of the 
success of women law-students at Paris, where Mile. 
Belcesco, a Roumanian girl, has just taken her degree 
as docteur en droit after obtaining the highest place in 
the licentiates' examination. A French lady and two 
of Russian birth also did well. Mile. Belcesco means 
to practise at the bar at Bucharest, confining herself 
to the cases of poor women who cannot pay counsel ; 
her thesis for admission to the Paris faculty contained 
seven hundred pages, of which two hundred were, 
with an exercise of prudence on the part of the lady, 
not read. The fact that not Portia herself would be 
allowed to practise in England no doubt explains why 
women have not yet carried off the honors of the law 
tripos at Cambridge. 



CHOLERA IN SPAIN. 

Dr. Oe Pietra Santa presents a coupd'ceil of the 
situation in Spain, in an article in La Journal d 1 Hy- 
giene, July 3d, which is translated for the Bulletin of 
the Marine- Hospital Service, July 18th. 

"A cholera epidemic has broken out in the province 
of Valencia, Spain. It showed itself on the 13th of 
May last at Puebla de Rugat, a village of 700 inhabi- 
tants. The disease cannot have been imported, the 
village being remote from the sea-board and having no 



suspicious outside communication. It is undoubtedly 
a local epidemic, caused it is asserted, by the turning 
up of earth in the vicinity of a sewer. It will be re- 
membered that in 1884 and 1886, Valencia was infected 
with cholera. The present epidemic is probably, there- 
fore, a fresh outbreak of the former epidemic. 

"From May 13th to June 15th one hundred persons 
were attacked; of these twenty died. 

"At Montechelvo there were seven deaths out of 
fourteen cases. The inhabitants left the town and the 
disease died out. One case is reported at Valencia 
and one death at Albaida. 

" The latest information received is that sanitary 
cordons have been placed around the infected localities, 
and that two-thirds of the population of these places 
have fled. It has been proposed to burn the earth 
infected by the sewers, an excellent means of disinfec- 
tion when it can be effectively practised. The quar- 
antine applied in the sea-ports of the provinces against 
outside communication would seem an unnecessarily 
stringent measure. 

" The cholera epidemic of 1884 was especially severe 
in the province of Alicante. Valencia was visited that 
year by the epidemic, but only to the^ extent of 300 
cases. In 1885, according to official statistics, there 
were more than 300,000 cases of cholera in Spain and 
more than 100,000 deaths, of which 21,612 occurred 
in the province of Valencia. It is also known that 
cholera was observed in Spain up to the beginning of 
the year 1886. 

" The following sanitary facts may not be without 
importance in this connection : 

"The city of Valencia has no system of cesspools. 
Private drains empty directly into immense sewers, 
constructed by the Moors hundreds of years ago, and 
which it is impossible to flush in a dry, warm 
country which has a slender water-supply. Many of 
the houses are ill-ventilated, ill-lighted, of bad con- 
struction, and with slight communication with the outer 
air. It was in such localities that the greatest number 
of cholera cases were observed during the epidemic of 
1885. 

" It is much to be desired that Spain should abandon 
the effete system of quarantine, which does more harm 
than good and which is equally opposed to sound scien- 
tific and humanitarian principles." 



A CASE OF GREATLY PROLONGED GESTA- 
TION. 

Dr. Richard Wilson reports in the University 
Medical Magazine for July, 1890, a case of interest in 
the above connection : 

" Mrs. M., aged twenty-nine years ; married Febru- 
ary 27, 1889 ; was regular all her life ; saw her menses 
last on March 1 L, 1889. She says she felt motion in 
July. If we add 280 days to March 11th, we get 
December 16th. the day on which the child might be 
expected. On January 30, 1890, as the child was not 
yet born, Dr. G. P. Sargent of Bryn Mawr, the attend- 
ing physician, called Dr. Atlee in consultation. On 
examination he found the ' child in the usual position ; 
the back forward, the breech upward ; the body inclined 
toward the right side of the belly, as the hand felt up- 
ward. In the vagina a hard head was felt. The neck 
of the womb was about half an inch in thickness, very 
soft, admitting the finger without much pressure.' On 



Vol. CXXIII, No. 4.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



95 



February 2d Dr. Atlee saw the patient again, and there 
was no change in her condition, except that the neck 
of the womb was not thicker than a sheet of paper. 
As he heard nothing more of the case he supposed 
the labor had taken place. 

" The following note was received by him from the 
attending physician, after the middle of March, under 
date of March 17, 1890: 

" ' Mrs. M. was delivered of a boy at eight o'clock 
this evening. There is nothing unusual in the child's 
appearance. Weight about six or seven pounds. 
Delivery rather difficult, but without instruments. 
The funis was around the neck ; large child, very 
active ; both mother and child doing well.' 



" From March 11, 1889, the date of the last mens- 
truation, to March 17, 1890, the date of the labor, 
there were 371 days, or six days more than a year. 
Supposing that her menses were suppressed on March 
11th from some other cause than pregnancy, and that 
she had not become pregnant till the next menstrual 
period, which would be April 3, 1889 (adding twenty- 
three days, the usual time between the catamenia), then 
the duration of pregnancy (from April 3, 1889, to 
March 17, 1890) would be 348 days, or 11 months 
and 14 days, which is two and a half months beyond 
the usual term. But if this is the case, then she felt 
quickening at the third month, for, she says, she felt 
motion in July." 



REPORTED MORTALITY FOR THE WEEK ENDING JULY 12, 1890. 



Cities. 



New York 

Chicago . . 
Philadelphia 

Brooklyn . . 

St. Louis . . 
Baltimore 

Boston . . . 
Cincinnati 
New Orleans 

Pittsburgh . 

Milwaukee . 

Washington . 

Nashville . . 

Charleston . 

Portland . . 
Worcester 

Lowell . . . 

Cambridge . 

Fall River . 

Lynn . . 

Springfield . 
Lawrence 
New Bedford 

Holyoke . . 

Somerville . 

Brockton . . 

Salem . . . 

Chelsea . . 

Haverhill . . 

Taunton . . 

Gloucester . 

Newton . . 

Maiden . . 

Waltham . . 
Fitchburg 
Attleborough 

Pittsfield . . 

Quincy . . 
Newburyport 

Woburn . . 



Estimated 
Population 
for 1890. 



622,237 
,100,000 
,061,277 
852,167 
550,000 
500,343 
418,110 
325,000 
260,000 
210,000 
240,000 
230,000 
68,513 
60,145 
42,000 
81,622 
73,370 
67,026 
64,092 
55,200 
41,520 
41,058 
38,218 
37,867 
35,516 
30,811 
29,242 
28,781 
27,124 
25,544 
24,904 
22,011 
20,615 
17,998 
17,304 
15,994 
15,762 
14,114 
13,915 
13,089 



Reported 
Deaths in 
each. 



1157 

443 
553 
606 
198 
260 
194 
155 



101 

34 
35 
10 
31 
41 
29 
56 
29 
17 
30 
20 



15 
10 

9 
5 
7 

5 
2 
3 

3 
5 
7 



Deaths 
under Five 
Years. 



697 
246 
294 
406 
127 
121 
79 
83 



50 
15 
15 
1 
16 
25 
13 
42 
4 
9 
17 



Percentage of Deaths from 



Infectious 
Diseases. 



36.16 
30 59 
27.18 
40.63 
27.50 
34.96 
21.42 
21 45 



2.07 
23.52 
14.30 
10.00 
22.61 
36.60 
27.60 
66.23 

3.45 
23.52 
36.63 
20 00 



13.33 

55.55 
40.00 



42.84 



Consump- 
tion. 



9.04 
8.74 
7.02 
7.65 
7.50 
4.70 
13.77 
5.85 



.90 
8.82 
5.72 
20.00 
16.15 
9.76 
10.35 
7.16 
13.80 
17.64 
6.66 
15.00 



6.66 
20.00 



20.00 



20.00 



Diphtheria 
and Croup. 



1.92 
2.07 
1.62 
3.40 
1.50 
1.14 
3.06 
1.95 



3.58 
13.33 



6.66 



42.84 



Diarrhoeal 
Diseases. 



29.36 
22.77 
19.98 
34.68 
18.50 
25.38 
15.30 
18.20 



1.44 

11.44 

19.38 
31.72 
24.15 
60.86 

23.52 
20.00 
20.00 



6.66 

44.44 
10.00 



Typhoid 
Fever. 



.48 
4.37 
2.34 

.68 
1.00 
3.80 

.51 

.65 



.54 
2.94 

10.00 

2.44 



11.11 



Deaths reported 4,070 ; under five years of age 2,191 : principal 
infectious diseases (small-pox, measles, diphtheria and croup, 
diarrhoeal diseases, whooping-cough, erysipelas and fevers) 1,340, 
consumption 351, acute lung diseases 192, diarrhoeal diseases 
1,050, diphtheria and croup 91, typhoid fever 66, whooping-cough 
43, measles 30, cerebro-spinal meningitis 23, scarlet fever 15, 
malarial fever 13, erysipelas 6. 

From whooping-cough, New York 14, Philadelphia 9, Brook- 
lyn 5, Boston 3, St. Louis, Baltimore and Nashville 2 each, 
Washington, Charleston, Fall River, Lawrence, Salem and Taun- 
ton 1 each. From measles, New York 25, Baltimore 2, Philadel- 
phia, Brooklyn and Boston 1 each. From cerebro-spinal menin- 
tis, St. Louis 8, Chicago 5, New York 4, Baltimore 3, Brooklyn, 
Worcester and Cambridge 1 each. From scarlet fever, New 
York 5, St. Louis 3, Philadelphia and Baltimore 2 each, Chicago, 
Brooklyn and Lynn 1 each. From malarial fever, New York 
and Baltimore 4 each, Brooklyn 3, Nashville 2. From erysip- 
elas, New York 3, Boston, Cincinnati and Lowell 1 each. 

In the twenty-eight greater towns of England and Wales with 
an estimated population of 9,715,559, for the week ending June 



28th, the death-rate was 16.9. Deaths reported 3,158: acute 
diseases of the respiratory organs (London) 206, measles 151, 
diarrhoeal diseases 102, whooping-cough 80, scarlet fever 44, 
diphtheria 42, fever 27, 

The death-rates ranged from 10.6 in Bradford to 27.1 in 
Manchester: Birmingham 19.1, Bolton 18.9, Hull 14 6, Leeds 

19.2, Liecester 14.5, Liverpool 18.6, London 15.9, Nottingham 

11.3, Newcastle-on-Tyne 23.7, Sheffield 19.6, Sunderland 17.2. 
In Edinburgh 17.3, Glasgow 23 6, Dublin 22.5. 

In the twenty-eight greater towns of England and Wales with 
an estimated population of 9,715,559, for the week ending July 
5th, the death-rate was 17.4: deaths reported 3,236: acute 
diseases of the respiratory organs (London) 244, diarrhoea 150, 
measles 132, whooping-cough 92, scarlet fever 45, diphtheria 29, 
fever Hi. 

The death-rates ranged from 6.7 in Brighton to 25.3 in Man- 
chester: Birmingham 16.9, Hull 14.6, Leeds 20.4, Leicester 16 6, 
Liverpool 16 7. London 17.5, Newcastle-on-Tyne 18 9, Notting- 
ham 14.1, Sheffield 16.1. 

In Edinburgh 14.6, Glasgow 24.5, Dublin 23.1. 



96 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 24, 1890. 



The meteorological record for the week ending July 12, in Boston, was as follows, according to observations furnished by 
Sergeant J. W. Smith, of the United States Signal Corps: — 



Week ending 


Barom- 
eter. 


Thermometer. 


Relative 
Humidity. 


Direction of 
Wind. 


Velocity of 
Wind. 


State of 
Weather.* 


Rainfall. 


Saturday, 


3 


a 

3 


g 


B 








a 

a 




















q| 


a 


July 12, 1890. 




o 

s 


3 

s 

M 


J 
G 


S 

■< 




a 

b 


9 

a 


S 
<4 




a 

Ph 


B 

«£ 




a 

A 


a 
4 




s 


£ 2 


a 2 








a 












































'5 


■3 


s 


i 










■3 







O 























Q 


Q 






06 




06 


Q 


00 




QO 


06 






00 




CO 




< 


Sunday,. . . 6 


30.06 


66.5 


76.0 


59.0 


57 




64 


60.5 


N.W. 




s. 


5 




10 


c. 




c. 






Monday, .. 7 


30.01 


72.0 


82.0 


62.0 


53 




63 


68.0 


W. 




S.W. 


3 




16 


c. 




F. 






Tuesday, . . 8 


29.80 


79.5 


92.0 


67.0 


71 




71 


71.0 


S.W. 




£. 


12 




18 


0. 




C. 






Wednes. . . 9 


29.76 


74.0 


83.0 


65.0 


44 




44 


44.0 


W. 




N. 


21 




24 


F. 




c. 






Thursday,. 10 


30.06 


61.5 


70.0 


53.0 


53 




51 


52.0 


N.W. 




N. 


10 




12 


C. 




0. 






Friday, ....11 


30.21 


61.0 


68.0 


54.0 


55 




84 


70.0 


N.E. 




E. 


9 




4 


c. 




c. 






Saturday,. 12 


30.11 


63.5 


72.0 


55.0 


57 




52 


54.0 


N.W. 




S.W. 


7 




12 


c. 




0. 






Mean for 
Week. 





























*0., cloudy ; C, clear ; F., fair ; G., fog ; H., hazy ; S., smoky ; R., rain ; T., threatening ; N., snow, t Indicates trace of rainfall. 



OFFICIAL LIST OF CHANGES IN THE STATIONS AND 
DUTIES OF OFFICERS SERVING IN THE MEDICAL DE- 
PARTMENT, U. S. ARMY, FROM JULY 11, 1890, TO JULY 
18, 1890. 

By direction of the Secretary of War, leave of absence for 
three months, to take effect September 15, 1890, or as soon 
thereafter as his services can be spared, is granted Captain 
William H. Arthur, assistant surgeon. Par. 1, S. O. 160, 
A. G. O., Washington, D. O, July 11, 1890. 

By direction of the Secretary of War, the leave of absence, on 
surgeon's certificate of disability, granted Captain Louis M. 
Maus, assistant surgeon, in Special Orders 4, January 6, 1890, 
from this office, is extended six months, on account of sickness. 
Par. 10, S. O. 160, A. G. O., Washington, D. C, July 11, 1890. 

By direction of the Secretary of War, leave of absence for 
four months, on surgeon's certificate of disability, with permis- 
sion to leave the Division of the Missouri, is granted Captain 
William H. Corbu.sier, assistant surgeon. Par. 4, S. O. 162, 
A. G. O., Washington, D. C, July 14. 1890, 

Leave of absence for one mouth, to take effect the 30th in- 
stant, is granted Colonel Charles Page, assistant surgeon 
general, medical director of the department. Par. 3, S. O. 91, 
Department of the Missouri, St. Louis, Mo., July 14, 1890. 

By direction of the Secretary of War, leave of absence for two 
months is granted Captain John F. Phillips, assistant surgeon. 
Par. 4, S. O. 104, Headquarters of the Army, A. G. O., Wash- 
ington, D. C, July 16, 1890. 



OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS 
OF THE U. S. NAVY FOR THE WEEK ENDING JULY 
19, 1890. 

Auzall, E. W., assistant surgeon, detached from U. S. S. 
" Galena" and wait orders. 

Eckstein, A. C, surgeon, granted leave of absence for month 
of August. 

Penrose, T. N , medical inspector, granted leave of absence 
for two weeks. 

Cabell, A. G., passed assistant surgeon, granted leave of ab- 
sence for the month of August. 

Ashbridge, Richard, passed assistant surgeon, granted one 
month's sick leave. 

Heyl, T. C, surgeon, granted leave of absence for the month 
of August. 

Cooke, Geo. EL, medical inspector, detached from Navy 
Yard, League Island, and to the " Pensacola." 

White, C. H., medical inspector, detached from the " Pensa- 
cola," proceed home and wait orders. 

HocHLiNti, A. A., medical inspector, detached from Naval 
Hospital, Washington, and to League Island Navy Yard. 

Wells, II. M., medical inspector, detached from Museum of 
Hygiene and to Naval Hospital, Washington, D. C. 

Whitfield, Jamks M., assistant surgeon, ordered to U. S. S. 
" Ajax " and other Monitors. 

Woolverton, T., medical inspector, ordered to the U. S. S. 
" Philadelphia." 

Lovering, P. A., passed assistant surgeon, detached from the 
U. S R. S. " Wabash " and to the U. S. S. " Philadelphia." 

Bailey, '1' 1' , assistant surgeon, detached from the U. S. R. S. 
" 6t. Louis " and to the U. S. S. " Philadelphia." 



White, S. S., passed assistant surgeon, ordered to the Marine 
Rendezvous, San Francisco, Cal. 



OBITUARY. 

DANIEL WATERHOUSE NILES, M.D., M.M.S S. 

Dr. Daniel W. Niles died at his residence, in Worcester, Mass., 
July 17th, after a short illness, aged sixty-three years He ob- 
tained his diploma at Dartmouth Medical School, and soon after 
settled in Worcester. The deceased was a veteran of the war, 
having enlisted in the 19th Massachusetts unattached. He 
was also a member of George H. Ward Post 10, Grand Army. 
He was a member of the Worcester District Medical Society and 
the Massachusetts Medical Society. About a dozen years ago 
he was city physician for one year. 



BOOKS AND PAMPHLETS RECEIVED. 

A Study of the Hygienic Condition of our Streets. By Charles 
N. Dowd, M.D., New York. Reprint. 1890. 

The Annual Statistics of Manufacturers, Massachusetts, 1889. 
Public Document. Boston: Wright & Potter, State Printers. 
1890. 

Transactions of the South Carolina Medical Association. 
Fortieth Annual Meeting held in Laurens, S. O, April 23 and 
24, 1890. 

Publications of the Johns Hopkins Hospital. Description of 
the Johns Hopkins Hospital. By John S. Billings, M.D., Balti- 
more. 1890. 

A Case of Locomotor Ataxia Associated with Nuclear Cranial 
Nerve Palsies and with Muscular Atrophies. By Frederick 
Peterson, M.D. Reprint. New York, 1890. 

Lecons Cliniques Bur les Maladies de l'Appareil Locomoteur 
(Os, Articulations, Muscles). Par le Dr. Kirmissou, Professeur 
Agre'ge' de la Faculte' de Me'decine, Chirurgien de l'Hopital des 
Enfauts Assiste's, Membre de la Socie'te de Chirurgie. Avec 40 
figures dans le texte. Paris: G. Masson, Editeur. 1890. 

A Digest of Current Orders and Decisions, with Extracts from 
Army Regulations, Relating to the Medical Corps of the United 
States Army. Compiled under direction of the Surgeon-General 
by Charles R. Greenleaf, Major and Surgeon, United States 
Army. Washington: Government Printing Office. 1890. 

Transactions of the American Pediatric Society, First Session, 
Washington, D. C, September 20th, and Baltimore, Md., Sep- 
tember 21, 1889. Together with the Proceedings of the Meeting 
for Organization held in Washington, D. O, September 18, 1888. 
Edited by Wm. Perry Watson, A.M., M.D., Recorder. Vol. I. 
Printed by J. B. Lippincott Co. 1890. 

Clinical Diagnosis: The Bacteriological, Chemical and Micro- 
scopical Evidence of Disease. By D. Rudolph v. Jaksch, Pro- 
fessor of Special Pathology and Therapeutics, and Director of 
the Medical Clinic in the German University of Prague. Trans- 
lated from the Second German Edition. By James Cagney, 
M.A , M.D., Demonstrator of Anatomy at St. Mary's Hospital 
Medical School, etc. With an appendix by William Stirling, 
M.D., Sc.D., Brackenbury Professor of Physiology and Histo- 
logy in the Owens College, Manchester, etc. With numerous 
illustrations (partly in colors). London : Charles Griffin & Co. 
Philadelphia: J. IS. Lippincott Company. 1890. 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



97 



Hectare. 



INFLUENZA IN MASSACHUSETTS. 1 

I1Y (1KOKQK B. S1IATTUCK, M.D., OF BOSTON. 
WORCESTER COUNTY. 

This county occupies the heart of the Commonwealth, 
and stretches across it from north to south. Though 
studded with manufacturing towns, it has a larger agri- 
cultural population proportionately than the counties 
previously considered. It may be regarded as a more 
homogeneous area than such counties as Barnstable or 
Bristol or Essex or Middlesex. I have tabulated 
twenty-seven returns from manufacturing companies, 
banks, etc., covering 11,405 employees. 

The returns indicate that the epidemic affected 
Worcester County in general later than those counties 
we have already gone over to the east of it. The 
earliest first case is returned from Clinton, the Bigelow 
Carpet Works, December 16th, but the maximum 
week was the second week of January ; and the Lan- 
caster Mills, at the same place, reports the first case 
December 26th, with the same maximum week; West 
Upton reports a first case December 21st, but as a 
maximum week the third week in January ; and a fac- 
tory, in the contiguous town of Grafton, reports its 
first case January 9th, with the third week of January 
also as the maximum week. A shoe shop in Worces- 
ter reports a first case December 23d, and a maximum 
week January 4th to 11th; but the first case at the 
bank which reports was December 30th ; and at 
the Loom Works, 500 employees, January 1st ; a 
Worsted Company in Fitchburg reports its first case 
December 20th, but its maximum week the second 
week of January ; and another company in Fitchburg 
dates its first case January 1st, and its maximum week 
the third week of January. Fourteen first cases are 
dated between January 1st and 10th, and the others in 
the last days of December. Eight returns give the 
third week of January as the maximum week, and 
fourteen the second week, one gives the fourth week. 

The percentages of those attacked vary from 60% 
to 5%, and of those absent from work from 60% to 
" very few " — that is, less than 5%. 

The Cotton Manufacturing Company of West Boyls- 
ton, with 226 employees, reports "only one case, and 
that early in January." The average absence from 
work was between five and six days. 

Medical Returns. — I have tabulated sixteen medi- 
cal returns from thirteen different towns. The earliest 
first case, December 15th, is from Grafton, where the 
manufacturing company dated its first case January 9th, 
but the maximum week was the second week of Jan- 
uary. Five returns — one each from Westborough, 
Worcester, Clinton, and two from Fitchburg — date 
the first cases December 20th ; the other returns vary 
from December 22d to January 3d, this latter another 
return from Fitchburg. Ten returns name the second 
week of January as the maximum week, and four the 
third week. 

The estimates of the percentages of population 
affected vary from 90% to 10%. Of two returns from 
Worcester, one says 90%, and one 50% ; of three re- 
turns from Fitchburg, one says 65%, one 25%, one 
10% ; the medical examiner at Gardner, near Fitch- 

1 Delivered before the Massachusetts Medical Society June 10, 
1890. Concluded from page 77 of the Journal. 



burg, estimates 80% for his district. The average 
is 48%. 

Sex. — Twelve reply males, and two females. 

Other Diseases. — Twelve say that pneumonia was 
increased, one that pulmonary diseases were increased, 
and one that whooping cough was more fatal. 

The next belt of the State to the westward may be 
regarded for our purposes as made up of three counties, 
Hampden, Hampshire and Franklin — in that order 
from south to north. The centre of these counties is 
traversed by the rich farming lands of the Connecticut 
River Valley, and the abundant streams from the hills 
are utilized for manufactures. 

HAMPDEN COUNTY. 

I have tabulated twelve returns from factories and 
banks in this county, employing between four and five 
thousand people. A Springfield Bank and a Holyoke 
Bank (the only banks sending returns) report " no 
sickness " ; the Holyoke Blanket Company reports, 
" few sick at any time and did not interfere with work " ; 
and the Germania Mills (Cotton), Holyoke, report 
" no loss of time from influenza " ; but two thread 
companies at Holyoke report first cases December 24th 
and 26th, and the second week of January as the max- 
imum week. A Firearms Manufacturing Company at 
Springfield, 213 employees, reports its first case Janu- 
ary 1st, its maximum the second week of January ; 
10% affected, 5% absent an average of nine days. 

No return from this county gives any earlier maxi- 
mum week than the second week of January ; but there 
is a report of a first case from near Palmer, December 
18th, one from Ludlow a little farther west, December 
20th, one from Chicopee — again, a little farther west 
— December 24th, but the other return from Chicopee 
gives January 1st as the first case. 

There are some apparently more than usually accu- 
rate and interesting returns from a Duck Company at 
Palmer in the eastern part of the county, employing 
325 hands. The first case in the dressing shop is re- 
ported December 30th, and the maximum week the 
second week in January ; but the first case in the 
bleaching department did not appear until January 7th, 
and the maximum week in that department was the 
fourth week of January. In all the departments except 
the dressing, the first case was some time during the 
first week of January, and the maximum week was in 
seven departments the second, in one the third, and in 
one the fourth week of January. In the bleaching 
87% were affected and 75% absent an average of five 
days; in the dyeing 80% were affected and 35% 
absent an average of six days ; in the iron repair shop 
75% were affected and absent seven days ; in the weav- 
ing 66% were affected and absent an average of six 
days; in the other departments there were considerably 
less ; and least, 25% with an average of four days, in the 
spinning. 

Medical Returns. — I have tabulated thirteen medi- 
cal returns from eight different towns in Hampden 
County. The dates given for first cases range all the 
way from October 6th in Monson, at the southeast ex- 
tremity of the county, to December 26th at West 
Springfield and Holyoke in the northwest, and are so 
varied and unreliable that no conclusion can be based 
on them. One return from Palmer gives the date of 
the first case December 1st, but states that influenza 
did not become general until after Christmas. This 



98 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 31, 1890. 



agrees with the factory returns and is probably the 
true interpretation of the medical returns ; the maxi- 
mum weeks given indicate the same thing ; as do three 
different Holyoke returns dating first cases December 
1st, 20th, 26th, but all giving the first week of Janu- 
ary as the maximum week. 

Seven returns name the second week of January as 
the maximum week, five the first week, one the third 
week. The percentages of affected vary from 75% 
to 20%, and the average of eleven returns is 44%. 
One practitioner profited, apparently, but little by the 
epidemic, as he reports that only one-fourth of 1 % 
among his clients were affected. 

Sex. — In this county eleven returns state that males 
were most affected. One return says : " especially 
out-door laborers " ; one says : " male, those out- 
doors " ; one says : " the careless, and those who tried 
to keep going every day about their business and 
work." 

Other Diseases. — Eight returns state that pneumo- 
nia was increased and one that pulmonary diseases 
were ; three (one from Springfield and two from Hol- 
yoke) report malarial complications ; one return from 
Holyoke says it resembled " dengue." 

Dr. A. F. Reed, of Holyoke, writes : " Bronchitis 
was common in most cases, but the most prominent 
influences seemed to be a union of rheumatic and ma- 
larial forces in a hybrid action, and in my experience 
quinine failed to give as good effects as salicin." 

HAMPSHIRE COUNTY. 

From this county I have tabulated thirteen returns 
from manufacturing companies, employing about 4,000 
people. There is one return of a first case about " De- 
cember 1st," one December 9th, one December 13th, 
one December 15th ; but the maximum week in all of 
these returns is the second or third week in January. 
A factory in Northampton reports its first case Janu- 
ary 1st and its maximum week immediately thereupon 
— the first week of January ; but the first case at the 
Northampton Bank did not occur till January 5th. 
A silk company at Florence reports the first case De- 
cember 9th ; but a braid company at the same place 
reports its first case January 6th and its maximum week 
the second week of January ; the same maximum week 
as that given by the silk company. From the silk 
mill 20% were affected and absent an average of eight 
days, and from the braid mill 25%, an average of four 
days. Eight returns give the first case between De- 
cember 25th and January 7th ; nine returns name the 
second week of January as the maximum week, and 
three the third week. The percentages of those absent 
from work vary from 60% to 5% and the time about 
six days. 

Medical Returns. — I have tabulated eleven medical 
returns from seven different towns in Hampshire 
County. The dates of first cases vary from December 
15th to January 1st. From Ware three returns date 
the first case December 20th, 27th, 28th. From 
Northampton three returns date the first case Decem- 
ber 15th, 18th, 29th. One return names the first week 
of January as the maximum week, but all the others 
name the second week. One Northampton return 
gives 10%, one 25%, and one 75% as the proportion 
of the population attacked. One Ware return says 
10%, one 33%, and one 40% as the proportion of 
the population affected. The Easthampton medical 
return says 60% of the factory employees, but 40% 



of other population. The average of ten returns is 

39%. 

Sex. — These returns throw little light on sex. One 
return says, both sexes were most affected. 

Other Diseases. — Six returns say pneumonia was 
increased, one specifying lobular pneumonia. One 
return from Northampton says : " there was no pneu- 
monia, and all other diseases appeared to be abolished ; 
there was one death from delirium." In regard to 
this Dr. Seymour, medical examiner, reports the fol- 
lowing : 

" A man, thirty-two years of age, had influenza at 
his home in Springfield. He got out of bed, dressed 
and came to his parent's home here in a state of delir- 
ium. He left their house at 2 a. m., and was found 
wandering about the streets by a policeman, who took 
him to the station house. There he remained in a 
wild delirium until 8 a. m., when, as he became sileDt, 
the keeper went to visit him and found him dead. I 
viewed the body and these were all the facts I could 
ascertain." 

FRANKLIN COUNTY. 

This county, the most northern of the three occupy- 
ing the breadth of the State, is somewhat less thickly 
settled and less traversed by railroads than the two 
preceding. The manufacturing returns are scanty, 
and I have only tabulated one as apparently accurate. 

The Russell Cutlery Company at Turner's Falls, at 
about the centre of the county on the Connecticut 
River, returns its first case January 6th, its maximum 
week the second of January, and 33% of its employees 
were affected and absent an average of 6 days. 

Medical Returns. — I have tabulated five medical 
returns from five different towns. Three returns 
from the eastern part of the county, from Orange in 
the centre, Cooleyville at the south and Northfield at 
the north, give the first cases December 26th, January 
1st and December 23d respectively, and the maximum 
weeks as the second for the first two, and the third 
week of January for the last respectively. The med- 
ical return for Turner's Falls reports the first case 
December 26th, the return for Shelburue Falls farther 
to the west reports the first case November 15th; 
both of these returns name the second week of Janu- 
ary as the maximum. 

The percentage of populations affected according to 
these five returns varies from 75% to 50%, the aver- 
age is 66%. 

Sex. — Three returns state that males, and one 
that females suffered the more. 

Other Diseases. — Two returns state that pneumo- 
nia was increased. 

BERKSHIRE COUNTY. 

This county occupies the extreme western belt of 
the State from south to north. It also is less thickly 
settled than other counties, and communication be- 
tween many townships is less immediate and direct 
than is the case in some of the other counties. There 
are, however, a good many manufactories within its 
borders. 

I have tabulated returns from 16 factories, employ- 
ing nearly 5,000 people. A company at Housatonic 
in the southern part of the county, and one at Adams 
in the northern part, return the earliest first cases, 
December 25th and December 30th respectively ; the 
maximum week for the former being the first, and for 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



99 



the latter the third week of January. Seven first 
cases are dated January 1st, two January 6th, one 
January 7th, one January 8th, one January 15th, 
one January 18th. One return names the first week 
of January as the maximum week, four the second 
week, nine the third week, and one the fourth week. 
No conclusions as to sex can be drawn from returns 
in this county. One return says " neither or both." 

The percentages of the affected vary from 75% to 
5% with an average of 45%, and of those absent 
from work from 50% to 3%, with an average of 
22%, for an average of 5i| days. 

The Arnold Print Works at North Adams reports 
"the epidemic did not cause any serious annoyance " 
amoDg its 146 employees. This is striking, for of 
the two other manufactories reporting from North 
Adams one had 50% of its employees absent, an aver- 
age of six days, and the other 25%, an average of 
four days. 

Medical Returns. — I have tabulated sixteen medi- 
cal returns from nine different towns in Berkshire 
County. I am obliged to conclude that they are not 
of much value in determining the time when influenza 
assumed an epidemic character in this part of the 
State. The dates of first cases vary all the way from 
October 14th, at Montville, to January 8th, at Otis, 
neighboring towns in the southeastern corner of the 
county. At Montville the maximum week is reported 
to have been the third week of November. Evidently 
again a local outbreak. Two returns from North 
Adams each give December 15th as the date of the 
first case, the second week of January as the maxi- 
mum, and 50% as the percentage of population at- 
tacked. Of three returns from Williamstown, next to 
North Adams, two date the first case January 1st, and 
one December 19th ; the maximum week of one of 
the first two and of the last being the second week, 
the maximum week of the other being the third 
week of January. But the returns from Pittsfield 
are still more perplexing, of five returns, one dates 
the first case November 20th, one December 15th, 
one December 17th, one December 27th (this return 
mentions having seen a case November 27th), one 
January 5th, and the maximum weeks vary almost as 
much. From Sheffield, in the southwestern corner of 
the county, the first case is reported December 15th, 
but the maximum week did not arrive until the fourth 
week of January. 

The percentage of population affected vary from 
87% to 10%, with an average of 60%. 

Sex. — Eight returns state that males, and three 
that females were more affected ; one return says : 
" men complained the most, because it was their na- 
ture to, but women were really as sick." 

Dr. S. C. Burton, Chairman Pittsfield Board of 
Health, writes January 26th: "In our House of Cor- 
rection, of which I have medical charge, there were 
105 prisoners; of these 96 males, 9 females. Ventila- 
tion to the male prisons by windows on the north and 
south side, to the female prison by windows on the 
east and west side. The windows in the male prison 
were open most of the time. The hall man was the 
first taken sick January 11th, the following day twenty- 
four men were sick, the next morning eight were too 
sick to go to the shop. January 14th twenty more 
were taken sick, and one or two a day afterwards, 
until the number reached fifty-six, all males; not a 
single case in the female prison." 



Other Diseases. — Nine returns state pneumonia 
was increased; two that pulmonary diseases were in- 
creased ; one that capillary bronchitis was increased. 

SUMMARY OF GENERAL CONCLUSIONS. 

Some of these returns are evidently quite accurate, 
and some mercantile returns and those of some public 
institutions, as well as a much smaller proportion of 
those of physicians, are based upon carefully kept 
records ; other returns are only approximately cor- 
rect ; and still a third and not small class are mere 
guesses, which gain such value as they possess from 
the probability that the errors counterbalance each 
other. 

In drawing conclusions, I have considered the date 
of maximum weeks of more importance than the dates 
of first cases. 

The data furnished for Suffolk County by such 
sources as the Massachusetts and City Hospitals, the 
State Prison, the Post Office, the two large private 
banks quoted are probably pretty accurate ; as are the 
returns from the Pacific Mills (Cotton and Prints), 
Lawrence, Essex County, 4,200 employees; and from 
the Pemberton Cotton Mills, at the same place ; and 
from the Merrimack Mills (Cotton and Prints), Lowell, 
Middlesex County, 3,200 employees; and from the 
Bigelow Carpet Mill (Wools), Clinton, Worcester 
County, 1,050 employees ; and from the Palmer Duck 
Company, Hampden County, 325 employees. 

From these, collated with the mass of less evidently 
reliable returns which I have tabulated but not read, 
one may, perhaps, conclude that : 

I. Influenza appeared first in epidemic form at Bos- 
ton and its immediate vicinity ; that the epidemic 
dates there from the middle of December, although 
there were sporadic cases earlier ; that it culminated 
during the week between December 28th and January 
4th ; that it began to decline pretty rapidly from that 
date, although its after-effects still exhibit themselves 
in many forms. 

II. That the epidemic was from ten days to two 
weeks later at the Island Counties (Nantucket and 
Dukes) than at Boston ; that it was about a week later 
in Barnstable and Bristol Counties ; and a few days 
later, perhaps, in Plymouth and distant parts of Nor- 
folk Counties. 

III. In the northern parts of Essex and Middlesex 
Counties, the epidemic was from five days to a week 
later than at Boston. Most of the towns reporting in 
these counties, especially in Bristol, Essex and Mid- 
dlesex, are in constant, rapid and easy communication 
with Boston by frequent and crowded daily trains. 

IV. It is difficult to explain why these counties 
were attacked later than Suffolk, and at the same time 
why Nantucket and Dukes were attacked still later 
than these counties. Neither a miasmatic wave, nor 
contagion, nor yet the two combined, as we under- 
stand them, cover all the observations. 

V. The epidemic, apparently to some extent, radi- 
ated out from Boston as a first centre. That it be- 
haved in the same way with regard to the surroundings 
of other centres of population, notwithstanding the 
suggestive report of the medical examiner at Ayer 
Junction, and notwithstanding similar propositions 
made elsewhere, I cannot satisfy myself from these 
returns. Except as a larger centre of population, it is 
not apparent why Boston should have been attacked 
before other points as far east on the coast ; as a 



100 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 31, 1890. 



centre of population, it is not apparent why it should 
have preceded New York ; and neither geographically 
nor as a centre of population, why it should have 
anticipated London. 

VI. With many puzzling local variations, backward 
and forward, and many contradictions, the returns in- 
dicate a later development as we proceed westward 
in the State, until in Berkshire County we find the 
epidemic developed fully two weeks later than in Suf- 
folk ; several days (four to five days) later than in 
Worcester ; and about as much later than in the two 
Island counties to the extreme east. 

VII. To judge from the returns of public institu- 
tions and of manufacturers, at least 40% of the adult 
population was seriously enough affected to have occu- 
pation interfered with. The medical returns, which 
necessarily are often guesses, agree with this. A 
considerably larger percentage probably was attacked. 

VIII. The returns from two maritime counties indi- 
cate that exposure to atmospheric influences was an 
important factor, and men were more affected. On 
the other hand, where men and women were equally 
confined within doors by their work, as in mills, the 
women were both more seriously and more numerously 
affected. 

IX. Returns from the McLean Asylum, the Massa- 
chusetts Hospital, the Boston Children's Hospital, the 
Tewksbury Almshouse, indicate that officers and nurses 
were more attacked than patients, an observation which 
corresponds with others elsewhere, here and in Eu- 
rope. 

X. In studying the returns of different mills one 
meets with singular cases of immunity from or predis- 
position to the epidemic. It is a curious anomaly, that 
one cotton mill should have less than half of one per cent, 
of its employees affected, and another 60% ; that a 
silk mill should have 60% affected, a woollen mill in 
a contiguous township 15%, and a cotton mill in the 
next township 6%. The percentage of affected at sev- 
eral of the woollen mills is quite small, but this is not 
invariable, at others it was as high as 40%. 

At print works there was a great variation in the 
percentages in different departments. From the Merri- 
mac Manufacturing Company of Lowell, which kindly 
sent me special figures, I learn that the "departments 
having a hot, moist atmosphere were subject more 
severely to the effects of the disease, which was also 
more prevalent among the women and boys than among 
the men. The high percentage of the color shop 
(16%) was due more to the unhealthy nature of the 
room (which is cold and very draughty) than to the 
noxious influence of the chemical fumes. Such places 
as the print room (one case out of 55), indigo dye- 
house (no case out of 20), laboratory (no case out of 
12), where the fumes from the drugs and chemicals 
are most conspicuous, were, comparatively speaking, 
free from any attack by the epidemic." 

At the paper mills, where many operatives are ex- 
posed to a warm, moist atmosphere, the percentage of 
affected was, as a rule, low. How far this was acci- 
dental, or how far due to chloride of lime or other ma- 
terials used in bleaching, may be queried. At the 
bleacheries of print works about 30% were attacked. 
At the bleaching room of the Palmer Duck Company 
87% of the employees were attacked. 

The Arnold Print Works at North Adams reports 
that the epidemic " did not cause serious annoyance " ; 
whereas the Greylock Mills (woollen) at the same 



place reports 75% attacked, and 50% absent from 
work an average of six days. 

The Merrimac Print Works (all departments in- 
cluded), Lowell, had 18% affected; The Pacific Mills 
Print Works, Lawrence, had 29.50% affected; the 
American Print Works, Fall River, had 33% affected. 

XI. Pneumonia was undoubtedly much increased in 
frequency during the influenza period all over the 
State. As to the character of the pneumonia — 
whether lobular or lobar ; croupous, fibrinous or catar- 
rhal ; whether mistaken for capillary bronchitis — 
these returns give little information, and one must con- 
sult special papers — such as those read April 17, 1890, 
before the New York Academy of Medicine by Drs. 
F. C. Shattuck, E. G. Janeway and William Pepper. 

XII. Some of the returns indicate that the presence 
of epidemic influenza was inimical to ("drove out") 
other forms of disease — as diphtheria and scarlet 
fever. 

In the Connecticut River Valley, as might have 
been anticipated, it seems to have taken a malarial 
character. 

XIII. To fit the mode of progression of the atmos- 
pheric disease wave — if the epidemic was dependent 
upon a miasmatic poison — with recorded observations 
in Europe and America, will tax the utmost ingenuity 
of the scientific meteorologist. 

XIV. The epidemiologist will be quite as much per- 
plexed if he seeks to explain all the phenomena by 
contagion. 

I have endeavored to collate carefully returns as 
made, and to follow honestly where they seemed to 
lead without prejudice, and without regard to previous 
mental predispositions. When the returns seemed to 
offer no exit I have said so. Some errors have doubt- 
less crept in, and some obvious lessons may have been 
overlooked. The picture, however, has not been var- 
nished at the expense of truth. 

The results are meagre enough, but they have yet 
to be compared with others before we quite despair of 
reaching some definite knowledge of epidemic influenza. 
The bacteriologist has failed to help us, and we must 
still struggle with the intricate problems presented 
without the aid of a specific micro-organism. 

Under date of January 5, 1890, Hirsch, the distin- 
guished Berlin epidemiologist, writes in answer to the 
editor of the Deutsche Medicinische Wochenschrift : 

... "I am persuaded that the present epidemic 
differs in no essential particular from those hitherto 
described. The great interest which the outbreak of 
this disease has excited is to be explained simply by 
the indifference of the great mass of the medical public 
to everything taught by history. . . . 

" Whatever I had to say about influenza I have said 
in the second edition of my historico-geographical 
pathology, and nothing new has presented itself." 



— The medical department of the University of 
Vermont at Burlington has adopted a requirement 
for a three years' course of study and lectures, instead 
of two, as formerly. And as a prerequisite, students, 
upon entering hereafter, will be required to pass an 
entrance examination, which shall be equivalent to the 
examination " required of such medical students by the 
board of regents of the University of the State of New 
York," 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



101 



THE NKCKSSITY FOR SOCIAL AND STATUTE 
RECOGNITION OF SYPHILIS. 1 

BY C. IRVING PISHKK, M.D., 

Superintendent of the Stale Almshouse, Tetcksbury , Muss. 

Thk present is a time for the facing and discussing 
of social problems. The spirit of true philanthrophy 
is abroad, and subjects, which a few years ago might 
not be mentioned in polite society, are to-day engaging 
the attention of able men and women throughout the 
land. 

Crime and pauperism, which seemed to have little 
interest for the honest, law-abiding, self-supporting 
citizen, are now being studied from entirely new stand- 
points. The fact is being recognized that mental and 
moral blight have their basis in disordered physical 
conditions, and are often the result of immorality trans- 
mitted through lines of inheritance. "The fathers 
have eaten sour grapes, and the children's teeth are 
set on edge." 

Students and lawmakers alike have ignored the fact 
that syphilis is present in every community, that it is 
an underlying factor of weakness in a large per cent, 
of the defective classes, that is, epileptics, feeble- 
minded, paupers, and low-grade criminals, and that the 
physical taint is the essential cause of the mental and 
moral degeneration. 

That it is not confined to the lower strata of society 
is well known to every physician, for in the very high- 
est social circles he meets and treats those who show 
unmistakable evidence of deflection from the paths of 
moral rectitude ; sins, perhaps, of long ago, but which 
no amount of repentance cau eradicate from the bodies 
of helpless ones to whom its effects have been com- 
municated. 

Every other serious infectious disease has been 
fenced in with legal enactments. A man with leprosy, 
yellow fever, small-pox, etc., is by law shut out from 
contact with others, nor can the physician with im- 
punity withhold from the proper civil authorities the 
fact that such diseases exist in his practice. 

For every other disease requiring prolonged and 
specific treatment, numbers of hospitals have been 
established by both public and private charity, but I 
know of not one that is open to receive syphilitic pa- 
tients as such. This is, perhaps, because the disease 
is the consequence of the violation of both divine and 
civil law. Public sentiment is not in sympathy with 
disregard of common morality, and is willing that the 
sufferer should reap the full harvest of his wrong doing. 
While this may be logical so far as the chief sinner is 
concerned, we seem to have lost sight of the fact that 
the penalty does not end with him. The sins of the 
parents visited upon the children run on in countless 
lines of defect and pain, and the best forces of the 
community are being drawn upon for the care of these 
impotent ones in homes, hospitals, retreats and alms- 
houses. 

That these conditions have so long existed undis- 
turbed, is due to the fact that the mass of thinking 
people, those who mould the best sentiment of the 
community, are unfamiliar with the disease. They 
scarcely know its name, and its wide-spread and dis- 
astrous prevalence are wholly unthought of. Enlight- 

1 Read before the Massachusetts Medical Society, Suffolk District, 
Section for Clinical Medicine, Pathology and Hygiene, May 21, 1890. 



enment in these lines must come through the physi- 
cians. To them alone will the public lend a listening 
ear on such matters as these. 

We have treated our patients, have discussed the 
various phases of disease with one another and in our 
exclusive and technical medical journals, but we have 
neglected golden opportunities to inform the public 
of its insidious nature and far-reaching destruction. 
Youth has been unprotected and parents unwatchful, 
because ignorant. Our work has been chiefly cura- 
tive. It should be broadened, and become educational 
and preventive. 

We who, in our daily walk, see on every hand what 
others do not see, the finger- touch of this monster 
evil, should "cry aloud and spare not," until our law- 
makers are forced to give us such enactments as shall 
enable us to hold in check " this pestilence that walk- 
eth in darkness, this destruction that wasteth at noon- 
day." 

" It is folly to exterminate diphtheria and small-pox 
and typhus, and let syphilis, the most prolific mother 
of evil of them all, send forth her brood of whelps to 
be the cause of more bodily and mental misery than 
all other shapes of human error combined." * 

It is made obligatory on the part of physicians to 
report to the proper civil authority the existence in 
their practice of such contagious diseases as small pox, 
diphtberia, etc., and persons so affected are strictly 
quarantined, and are not given their liberty until, in 
the opinion of the attending physicians, they are no 
longer liable to spread contagion. These maladies are 
in no way associated with dishonor or impurity. They 
may wipe out their victims from the face of the 
earth, but they leave no taint to be transmitted to 
descendants. 

If the State has a right to take into its custody one 
citizen, because he has a disease which is dangerous 
to other members of the community, it has certainly 
the right to take another into its custody whose dis- 
ease is not only dangerous to the present, but most 
woefully so to future generations, and which is devel- 
oped and perpetuated by the voluntary violation of 
both divine and civil law. Yet syphilis, which in 
some of its manifestations is more loathsome than 
small-pox, which is as destructive, infectious and far- 
reaching as leprosy, which probably causes more deaths 
annually than all the epidemics which visit our land, 
is not recognized upon the statute book. 

It does not appear as the cause of death upon the 
physician's certificate or books of statistics, because 
the practitioner does not always recognize it, or be- 
cause out of kindly consideration for the friends of the 
deceased, he writes instead the name of the complicat- 
ing trouble. " Rheumatism is written over the graves 
of strong men crippled in their prime ; scrofula hides 
the secret sin of the parent stamped upon the slender 
frame of the invalid child ; cancer is the foul lie buried 
with the wife, who has silently suffered the most ex- 
cruciating agony which human flesh can endure." * If 
the impossible were possible, and we were able to 
gather the statistics regarding this disease, they would, 
I believe, be more appalling than aiiy medical statistics 
ever presented. 

" Grant that the individual may play what havoc he 

* The quotations marked with an asterisk (*), on this page and 
the following one, are from the address entitled "Protection from 
Venereal Diseases." by Albert H. Gihon, Medical Director, U. S. N., 
before the American Public Health Association, at Nashville, Tenn,, 
in 1879. 



102 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 31, 1890. 



chooses with himself and his happiness, society has 
the right to demand that self indulgence shall bring no 
evil to a single other being than the transgressor." 
"No one questions the contagiousness of syphilis, or 
that its spread is the result of personal contact, and 
by what right any man or woman suffering with it 
may not only live in freedom, but actually solicit 
victims, it is difficult to understand." * 

My point of observation has been among the low- 
grade criminal classes for four years and a half at the 
Deer Island Institutions, and for nearly seven years 
at the State Almshouse at Tewksbury. It is my for- 
tune to-day to be caring for men and women, in the 
latter place, whom I began to care for more than nine- 
teen years ago in the former place. Then they were 
active sneak-thieves, drunkards and prostitutes, now 
they are the " worthy poor " for whom the majority 
of good citizens think we "cannot do enough." The 
State Almshouse has a constant population of nearly 
1,000 people. Last year, of 2,009 persons admitted 
to the institution, 1,721 were sent to the hospitals. 
Large experience in handling these people has led us, 
in our medical work, to make a thorough physical ex- 
amination for evidences of syphilis, whatever the his- 
tory given or symptoms complained of. We have 
found that many cases of rheumatism, paralysis, neu- 
ralgia, etc., respond to the orthodox remedies only, 
when they are combined with iodide of potash, or the 
green iodide of mercury. 

During the year ending March 1, 1890, there were 
admitted to the hospital 1,058 men. Of these one had 
congenital syphilis; 54 had primary or secondary le- 
sions well marked ; while 496 had tertiary symptoms 
more or less active — a total of 551 syphilitics, or 
more than 52% of the whole number admitted. The 
statistics from the female hospital are not given, 
because the specific examinations were not instituted 
there until later, and do not cover a whole year. I 
believe, however, that the above figures would not be 
material 1)' changed were all the hospital departments 
included. 

Next to intemperance, I hold that syphilis is the 
most important factor in the development and perpet- 
uation of the dependent classes. There is not a tissue 
of the body which is exempt from its subtle and un- 
dermining influence. It renders the system more lia- 
ble to other diseases, behind which it hides itself as 
under a mask. It is ever present as a factor of de- 
pression, weakening the will, lessening the vigor of 
manhood, and lowering the sense of responsibility. 
Whatever may be said of the curability of syphilis, it 
is practically incurable in the classes with whom I am 
in contact. They do not appreciate the nature of the 
trouble, nor will they, outside of a hospital, observe 
any of the conditions necessary for permanent relief. 
A large number go in and out, invariably improving 
while under medical observation, but degenerating 
rapidly when away and dependent upon their own re- 
sources. Finally, they come back to the almshouse 
with exhausted powers, to drag out a useless existence 
at public expense. Many of the children born in our 
hospitals show unmistakable evidence of syphilis which 
was not present in the mother, and which shows all too 
surely the character of those who beget illegitimate 
children. Pitiable indeed are these weak and sickly 
offspring of poisoned human bodies, and we can but 
cheerfully acquiesce in the interposition of Divine 
Providence which removes them from our sight and 



care while the unequal struggle for existence has just 
begun. If these children survive the diseases of child- 
hood and the neglect of ignorant or dissolute mothers, 
they, as a rule, go to swell the ever-increasing army 
of dependants which the State must carry as a dead 
weight, and at the maximum cost. 

To protect the innocent and helpless, and to check 
this ever-increasing burden upon the State, legislative 
action must be secured. But legal enactments will be 
successful only as they are the outgrowth of public 
opinion. The mind and conscience of the community 
must be enlightened and awakened. We who must 
stand as educators need not only courage, but tact to 
engage the attention and active co-operation of the 
leaders of thought. Those of us who are connected 
with hospitals, or who hold intimate relations with the 
trustees of such institutions, have special opportunities 
for initiative work. 

I believe the most rational approach to the object 
desired would be to secure the free admission of this 
disease to every municipal hospital and dispensary. 
In some of the larger cities special hospitals might 
be established. This would accomplish two things. 

(1) Some having the disease might be brought under 
treatment before their constitutions were so thoroughly 
undermined that they must be permanent dependants. 

(2) Statistics would be secured which could be used 
as educational factors, and so pave the way to such 
legislative enactments as the gravity of this disease de- 
mands. 

Adequate legislation will meet with some obstacles, 
however. A law which may touch the pleasure of 
some who indulge in crime behind the screen of wealth 
and respectability ; a law which may put to shame 
some in places of iufluence by bringing their secret 
sins to the light of day ; a law which in its execution 
may bow with grief worthy families because some 
honored and esteemed one is shown to be untrue and 
impure — such are not easy of enactment. 

But this, at least, may be secured, — that persons 
who have come under State control, whether as crimi- 
nals they have been committed to some criminal insti- 
tution, or have thrown themselves upon town, munici- 
pal or State bounty for support, if found to have syph- 
ilis, shall not be allowed to go out until the infectious 
stages are past, and they have been under medical ob- 
servation and treatment for a specified time. 

This would secure two things : (1) It would pre- 
veut not a small number of men and women from go- 
ing out of the houses of industry, jails and almshouses, 
and communicating the disease to others. (2) It would 
send men and women out in a fair degree of health and 
strength, able to earn a living and properly care for 
themselves, which is not the case uuder existing law 
and custom. To my personal knowledge, within a 
year two syphilitic women have gone out from the 
State almshouse, and have married — one having the 
initial lesion. Again, I have learned of a woman under 
sentence in one of our State prisons. She was young, 
with a pretty face and pleasing manner. She attracted 
the notice and won the confidence of certain visitors. 
They interested themselves in her behalf. They could 
not see what the physician saw, the vile taint under 
the fair exterior. Mistaken philanthropy prevailed, 
and the woman was pardoned — virtually, though not 
nominally, released on the ground of good looks. She 
went out, and in a few weeks had communicated her 
disease to many persons. 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



103 



Only day before yesterday there came to the alms- 
house, to visit her crippled, syphilitic child four years 
old, a well-dressed and, to all appearances, a healthy 
woman. She is a domestic in some home in this city. 
My conversation with her revealed the fact that the 
father of the child was a worthless fellow — she was 
not married — and that she had had a sore upon her 
lip, and later a sore mouth and throat, and that some 
physician had treated her, as she expressed it, for " the 
disease." 

I would submit the following form of enactment, as 
suitable to be presented to our legislature for its con- 
sideration : 

An Act to prevent the spread of syphilis by paupers and 
criminals. 

Be it enacted, That any inmate of any criminal or pub- 
lic charitable institution, who has syphilis, shall at once be 
placed under medical treatment and observation ; and such 
inmate shall not be discharged therefrom until three months 
after all infectious symptoms have disappeared. 

This act shall not be construed to apply to any institu- 
tion supported by private charity. 

These suggestions include only those lines along 
which it seems practicable to act now. Some Euro- 
pean governments have already established protective 
methods. New questions will arise here as public 
thought and feeling advance. As a step in educational 
work, why should it not be made obligatory upon the 
physician to place in the hands of his patient circulars 
regarding syphilis, such as are now furnished by boards 
of health relative to small-pox, diphtheria, scarlet fever, 
etc., telling the people how to care for the patient, and 
its dangers present and future ? 

We see this disease and its relations to the public 
welfare as no one else does or can. This work is a 
closed door to others. The key to the situation is in 
our hands. Every added knowledge brings an added 
duty and obligation. 

How often have we treated our syphilitic patient, 
knowing well his condition and the disastrous results 
which must come in the marriage relation he was about 
to consummate ; counting it " professional honor " to 
hold his dissolute secret, and sounding no word of 
warning to the healthy, honorable and innocent woman 
he was to marry — perhaps not even urging upon him 
the gravity of the situation, pointing out its far-reach- 
ing consequences, and appealing to his manhood to 
take the only honorable course, and spare the innocent 
and helpless ? 

How much longer shall we remain silent ? 

I believe the time will come when " professional 
honor " will have no part in holding the secret of one 
immoral, or even unfortunate, man or woman, when it 
is to bring disease, weakness, suffering and death to an 
unknown number of their offspring. The honorable 
majority of noble mothers and innocent children have 
rights which are not to be set aside by the dissolute 
minority. 

The facts presented, however unpleasant, are facts 
none the less ; and this disease must sooner or later 
receive the recognition which all other serious infec- 
tious diseases have received. The State will yet put 
its restraining hand upon the dissolute and vile, and 
exercise its legitimate power to preserve inviolate the 
manhood and womanhood of its citizens. 



— The Mesopotamian epidemic of cholera has com- 
menced to spread northwards towards the Black Sea. 



REPORT ON DISEASES OF CHILDREN. 

KV T. M. KOTCH, M.D., 
Assistant 1'rofessor of Diseases of Children, Harvard Medical School ; 
l'hysician to the Children's Hospital. 

winckkl's ihskask. 1 

An endemic of acute hajmoglobinuria in newly-born 
children was observed by Winckel, at Dresden, in 
1879, the symptoms being cyanosis, icterus, haemor- 
rhages from various organs, dark red discoloration of 
the renal pyramids, which contained streaks of haem- 
oglobin, and fatty degeneration of the liver and other 
organs. Nineteen of the children died on an average 
within thirty-two hours after the beginning of the 
symptoms. 

A few other cases have been reported by various ob- 
servers, the last one being that one recently carefully 
studied by Hirst {University Medical Magazine, March 
18, 1890) which occurred in the maternity pavilion of 
the University Hospital, Philadelphia. Labor was in- 
duced in the mother of the patient sixteen days before 
term, but was normal in other respects. The child, a 
female, appeared well-developed and was not asphyxi- 
ated. On the following day blisters were found on 
the legs and buttocks, probably the result of burning 
by hot-water cans. On the day succeeding this the 
body presented a brownish-green color, evidently a 
combination of cyanosis and icterus. The urine was 
of a dark red color, and contained methaemoglobin. 
Inhalations of oxygen relieved the cyanosis to a con- 
siderable extent, but on the fifth day the child died. 

Temperature was normal until the fourth day, 
when the thermometer registered 102° F. 

On examination of the blood the red cells num- 
bered 5,700,000. Three days later they equalled 
3,400,000 the ratio of white to red being 1 : 13.5, 
and the haemoglobin eighty-nine per cent. Poikilocy- 
tosis was well-marked. Bacteriological studies of the 
blood revealed the presence of the micrococcus. 

At the post-mortem examination the body was 
found emaciated, and with an icteric hue of the skin 
and mucous membranes. Several dark gangrenous- 
looking patches were seen, said to be the result of the 
contact of hot- water bottles. The lungs exhibited a 
large number of haemorrhagic infarcts of different 
sizes. The heart contained dark, fluid blood, and its 
muscle was somewhat degenerated. The cord and 
umbilicus were normal, as were the intestines and 
stomach. The liver seemed somewhat altered. The 
kidneys were cyanosed and injected. The mucous 
membrane of the bladder showed a number of pin- 
point foci of ecchymosis. The spleen was large and 
congested. The mesenteric glands were enlarged 
and hard. Microscopic examination showed cocci in 
the liver, kidneys, spleen and lungs. There was 
some fatty degeneration of the heart muscle, and in 
the kidneys there was globular nephritis. 

SECONDARY INFECTIONS IN SCARLET FEVER. 2 

The idea of a possible secondary infection has be- 
come too prevalent to allow it to pass without consid- 
eration. Chanin says that it results from penetration 
into the organism of a second microbe, which is added 
to and is distinct from the first. Before the idea of 
microbic infection was applied to the eruptive fevers 
the question had been raised whether the abnormal 

1 The American Journal of the Medical Sciences, April, 1S90. 

2 Guinon : Rev. Mens, des Mai. de l'Enf., September, 1889 (Ar- 
chives Pediatrics, April, 1890). 



104 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 31, 1890. 



phenomena, appearing in the course of these diseases, 
was of the same nature as the primary disease, and 
whether they resulted from external or internal con- 
ditions ; whether, in a word, they constituted a func- 
tion of the primary disease or were the manifestations 
of another disease engrafted upon the first. The dis- 
cussion of this subject has, of course, a practical as 
well as a theoretical side. Bouchard, after studying 
the local manifestations in general diseases of the 
character under discussion, has demonstrated that the 
accidents and complications in these diseases are al- 
most always new diseases, which are distinct from the 
original ones. The number and gravity of the com- 
plications occurring with scarlatina render it most 
suitable for the application of this theory. As a 
matter of fact, we do not as yet know the characters 
of the microbe of scarlatina, but we do know those of 
the micro-organisms which produce secondary infec- 
tions in that disease. Klein, Crookshauk and others 
have discovered micro-organisms which were supposed 
to be peculiar to scarlet fever, but their results are 
not entirely harmonious, and have not been entirely 
convincing. Leuhartz, Marie Raskin and Babes, on 
the other hand, have studied the blood, the viscera, 
and the organs especially involved in the complica- 
tions of scarlatina. In suppurative adenitis, Raskin 
found in seven cases, with or without diphtheria, a 
streptococcus which was constantly present. With 
tonsillar and pharyngeal ulcerations, Lenhartz found 
a thick layer of chains of streptococci, without the 
presence of gangrene, — that is, the streptococcus was 
evidently a secondary manifestation. In septicemia, 
occurring as a complication, absolute conclusions were 
not drawn. Raskin found a streptococcus and a 
small and oval micrococcus, but did not determine 
their nature nor their virulence. In the blood the 
streptococcus was rarely found. Raskin found it in 
only six cases out of twenty-three. Both Raskin and 
Babes found the streptococcus, with other microbes, 
in connection with complicating pleurisy, pneumonia, 
pericarditis and endocarditis. It was believed that 
the bacteriology of the pericardium was identical 
with that of the pleura. In scarlatinal pyaamia, in- 
vestigators are agreed that the streptococcus is the 
most frequent cause, but other microbes are found at 
the same time in the same organ, or in the other vis- 
cera. In nephritis, an important point to be decided 
is, whether the microbe acts upon the kidney by it- 
self or by the products which it secretes, and recent 
investigations tend to show that the former supposi- 
tion is the correct one. Raskin has found and isolated 
in the kidney the streptococcus alone or united with a 
micrococcus, a diplococcus, or a bacillus, and they 
were also found in other organs. BabtSs studied 
fourteen cases in which there were albuminuria and 
oedema, and in thirteen the streptococcus, alone or 
associated with the pneumococcus of Talainou-Framkel 
was found. In scarlatinal rheumatism, three forms 
or varieties must be distinguished, a serous non-Sup- 
purative form, a serous suppurative form and a form 
in which suppuration occurs at the outset. 

In the non-suppurative fluid of the synovial mem- 
brane Raskin found the streptococcus ; in purulent 
arthritis the streptococcus may be found in great 
numbers. In the pus of otitis Raskin constantly 
found the streptococcus, and in the later stages of the 
disease it was associated with the staphylococcus au- 
reus et staphylococcus albus. Iu diphtheria Raskin 



found streptococci, diplococci, micrococci, and Lceffler, 
in addition to the streptococci, found also the Klebs- 
LcefHer bacilli. 

From the foregoing it would appear that most of 
the complications in scarlatina are due, iu all proba- 
bility, to the action of a streptococcus, either iso- 
lated or associated with other microbes, and it has 
always presented the same character, with the excep- 
tion that it varies in virulence. It is probably identi- 
cal with the streptococcus pyogenes of Rosenbach, 
and Lenhartz thinks that it is modified in scarlatina 
by the primary infection. It is probably this organ- 
ism which causes death in scarlatina either directly by 
septicaemia or indirectly by nephritis. Secondary 
infection in this disease most frequently occurs by 
way of the pharynx, and the penetration of the mi- 
crobes is favored by the loss of epithelium by the 
dilatation of the lymphatic channels, and by the re- 
cumbent position which the sick child assumes. The 
foregoing indicates antisepsis of the throat in all the 
pyrexias of childhood, but especially in scarlet fever, 
and before any complications occur, but caustic or 
irritant applications must always be avoided because 
of their destructive action upon epithelium. 

\j INFANTILE HYSTERIA. 8 

According to Liebermeister, hysteria is the result 
of a functional disease of the gray matter of the brain. 
Hence it should be considered as a psychical disease, 
and not as a simple neurosis complicating psychical 
disorders. The view of Liebermeister is shared by 
other authors. They regard hysteria as essentially a 
psychical disease, because psychic symptoms are con- 
stantly manifest ; because, in many cases, they are 
the first or perhaps the only symptoms which appear ; 
because it is generally admitted that hypochondria, 
the analogue in the male of hysteria, is a psychosis ; 
and because one frequently sees, as hysteria develops, 
phenomena which leave no uncertainty as to the psy- 
chic character of the disease. While in adults hys- 
teria commonly shows a great complexity of symp- 
toms, the hysterical phenomena iu children are usually 
simple and clear. 

The authors have treated, in the hospital at Basle, 
since 1874, hysterical children to the number of three 
boys and twenty-one girls, which may be divided into 
three groups. Iu the first group were the most sim- 
ple forms of the disease, the morbid phenomena be- 
ing merely certain modifications of character, and cer- 
tain symptoms which differed little from the general 
disorders produced by anaemia. The second group 
included cases which were without violent attacks and 
without troubles of consciousness. In this class there 
was a tendency to localization of the disease, and the 
determination of such disorders as paresis, paralysis, 
contractures, localized anesthesia or hyperaasthesia, 
pra j .cordial anxety, aphonia, etc. In the third group 
were the cases which had convulsions with more or 
less loss of consciousness — the grand hysteria of 
Charcot. The following might be considered as its 
varieties: (1) attacks of hystero-epilepsy, or epilepti- 
form hysteria; (2) chorea major, or rythmic chorea; 
(3) spasmus nutans ; (4) tonic and clonic convulsions, 
usually atypical, occurring in paroxysms. With regard 
to etiology, it seems probable that predisposition has 
most to do with the origin of the disease, and this pre- 

» HageubacU, liurckhardt and Duvoisin : Rev. Meus. des Mai. de 
I'Knf ., September, 188<> (Archives Pediatrics, April, 1890). 



Vol. CXXIir, No. o.J BOSTON MEDICAL AND SURGICAL JOURNAL. 



L05 



disposition may be- hereditary, whether congenital or 
acquired. The hereditary predisposition was observed 
in fifty-eight per cent, of the author's cases. In fifty 
per cent, of the cases there was hereditary tuberculo- 
sis. The most important predisposing conditions of 
an acquired character are anemia and disorders of 
nutrition ; all but two of the cases in the given series 
being anaemic. In several of the cases whooping- 
cough had exercised an unfavorable influence upon 
the constitution ; in two there had been acute anterior 
polio-myelitis in early childhood. In eight cases fear 
and different local and general affections had exer- 
cised a decided influence. Of eight cases in which 
the first symptoms of hysteria were seen prior to the 
tenth year, there was hereditary predisposition in six. 
Of sixteen who did not become hysterical until after 
the tenth year, half of them had scarcely any heredi- 
tary antecedents. 

If hysterical children are early submitted to me- 
thodical treatment, improvement is usually observed 
within a short time ; but the subsequent history may 
be unfavorable. Of twenty-two cases, fourteen suf- 
fered relapse within four years after their discharge 
from the hospital ; and the others remained very 
anaiinic. Of eleven who were more than seventeen 
years of age, and who had been more than five years 
out of the hospital, only one remained in good health. 
The others had attacks of migraine, palpitations, ner- 
vousness, psychical and corporeal weakness, hysteri- 
cal psychoses, etc. In making a diagnosis of hysteria, 
epileptiform attacks and phenomena of simulation 
may cause much embarrassment. As to prognosis, 
Jolly and Briquet consider the disease a rebellious 
one, while Henoch and Weiss look upon it as devoid 
of gravity. It is sufficiently proven that it is subject 
to relapses and to psychical weaknesses. The treat- 
ment should aim, first, to combat the isolated symp- 
toms of the disease ; second, to act upon the general 
condition, and especially to relieve the anajmia. 

ASPIRATION IN CHRONIC HYDROCEPHALUS. 4 

Aside from the dangers of local infection which may 
be easily avoided by rigorously following antiseptic 
principles, puncture of the lateral ventricles may lead 
to other complications which deserve to be taken into 
consideration. There is, on the one hand, the entrance 
of air into the cranial cavity, and, on the other hand, 
arterial hyperaemia of the brain which may result from 
too rapid depletion of the ventricle. To avoid these 
accidents the author recommends the exercise of manual 
compression upon the cranium during the puncture, 
and care that the flow of liquid from the ventricle 
should take place slowly and regularly, and these two 
conditions may be realized with such an aspirator 
syringe as was described in 1867 by Mosler. 

With reference to the technique of puncture with 
the aspirator, it may be said that this can be best done 
through the anterior fontanel, and that the needle 
should be inserted away from the median line so as to 
avoid wounding the superior longitudinal sinus. Two 
cases in which this plan was tried by the author are de- 
scribed minutely. In the first, five punctures were made 
within six weeks, seven hundred and sixty grammes of 
serum being withdrawn. The improvement in the case 
was only transient. In the second case the punctures 
were made at longer intervals than the first, but the 

* Pfeitler: Rev. Mens, ties Mai. de l'Knf, December, 1888 (Archives 
Pediatrics, January, 1890). 



results were not more satisfactory. The conclusion 
from this experience might be that the effect of these 
punctures is almost nil, the withdrawal of the serum 
being almost immediately followed by its reproduction. 
Nevertheless this treatment need not be entirely re- 
jected, for there are several recorded cases in which a 
cure has been obtained ; and though tin; effect of the 
punctures might be only transient, they would facilitate 
to a certain extent and for a certain period of time the 
development of the nervous centres, and may be prac- 
tised without the least danger to the life of the chil- 
dren. When they are made with all necessary pre- 
cautions they are not followed by any local inflamma- 
tory reaction. 

For thoso cases in which phenomena of compression 
of the brain appear, with convulsions, etc., this mode 
of intervention is quite warrantable. 

PARACENTESIS IN INTERNAL HYDROCEPHALUS. 6 

The author exhibited a case of acquired chronic inter- 
nal hydrocephalus, for the relief of which he undertook 
paracentesis after trephining The patient was a boy 
nearly five years old. He was seized with convulsions 
when three months old, and these attacks, which be- 
came very frequent, continued for nine months and 
then ceased. Three months after their commencement 
his head became enlarged. Every form of treatment 
had been tried, but without the least success. 

Condition at the time of operation as follows : He 
was obviously imbecile ; he could not talk, but smiled 
idiotically ; he was totally blind ; but the other special 
senses were not apparently affected. He had never 
walked or stood alone, but could easily move his body 
and extremities. His bowel and bladder sphincters 
were not controlled. He was extremely irritable and 
restless. He was fairly developed physically, but 
always of an ashy pallor. There was a very frequent 
rotary movement of the head, with slight retraction 
and grinding of the teeth. 

The anterior fontanelle closed when he was eighteen 
months old, and the sutures had ossified at the usual 
time. The measurements of the head gave twelve and 
one-half inches from the glabella to inion ; thirteen 
and three-quarters inches over the biauricular line ; 
twenty inches around the fronto-occipital line. On the 
4th of December, 1888, the author operated upon the 
case. Under the most careful antiseptic precautions, 
with a trephine about one centimetre in diameter, a 
butt«n of bone was removed from over the coronal 
suture, about one and one-half inches to the right of 
the median line. A very delicate trocar was passed 
through the dural membrane into the brain-substance, 
downward, backward, and inward, to the depth of one 
and one-half inches, the object being to pierce the cen- 
tral cavity of the right lateral ventricle. About an 
ounce of a clear limpid fluid, closely resembling cerebro- 
spinal fluid, was evacuated, and, as the trocar was with- 
drawn, a small quantity of the same kind of fluid es- 
caped from the subdural space. For several days the 
same fluid continued to ooze from the puncture in the 
dura, and it was estimated that from four to eight 
ounces was thus discharged. 

The case progressed satisfactorily. In two or three 
days he could stand alone, and he was gradually able 
to walk alone across the room, which he did in 
about three weeks. There was a partial restoration 

<>Ayres: American Lancet, Detroit, 1889, xiii, 128 (Archives Pedia- 
trics, February, 1890). 



106 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 31, 1890. 



to sight. He became more attentive and seemed to 
understand better. He was less irritable and he slept 
well. The rotary movements of the head ceased. How- 
ever, there was no development of speech, nor were the 
sphincters under any better control. The author 
believes that more fluid will have to be evacuated, as 
the patient is not quite so active now as some time 
after the tapping. 

The chief difficulty lies in our inability to determine 
which cavity to evacuate. For instance, if the fluid 
resides in both cavities, and the normal openings be- 
tween them, through the foramen of Majendie, and 
those behind the roots of the glossopharyngeal nerves 
be closed by inflammatory exudation, or the presence 
of a tumor, then to tap only the subdural space would 
remove the external pressure, and allow such an ex- 
pansion of the internal fluid as would perhaps lacerate 
the brain-tissue. Or the same effect might be produced 
by evacuating only the ventricular fluid. This may 
have been the cause of death in some of the reported 
cases. 

TWO CASES OF LOSS OF HEARING CONSEQUENT UPON 
MUMPS. 6 

The first case was that of a boy, five and a half 
years old ; who had been subject to nasal catarrh, and 
frequently a discharge from both ears. One week after 
the onset of mumps, the hearing was suddenly lost, 
and there was marked giddiness, roaring in the ears, 
and pain in the back of the head. At the time of the 
report, six months later, the power of hearing was 
totally abolished, and the power of speech was nearly 
lost. The second case was that of a man thirty-five 
years of age. At twelve years, during an attack of 
mumps, the hearing was entirely lost and never had 
been regained. The tympanic membrane and Eustach- 
ian tubes were normal. 

The author believes that the lesions in both cases 
was in the labyrinth, but the nature of the pathological 
process is somewhat uncertain. 



Keport£ of £ocietie£. 



MASSACHUSETTS MEDICAL SOCIETY, 
SUFFOLK DISTRICT. 
SECTION FOR CLINICAL MEDICINE, PATHOL- 
OGY AND HYGIENE. 

ALBERT N. HI.ODGETT, M.I)., SECRETARY. 

Regular Meeting, Wednesday, May 21, 1890, Dr. 
A. I,. Mason in the chair. 

Dr. C. Irving Fisher, Superintendent of the 
State Almshouse at Tewksbury, Mass., read a paper 
on 

THE NECESSITY OF SOCIAL AND STATUTE RECOG- 
NITION OF SYPHILIS. 1 

Dr. F. B. GreenoUGH: I shall have very few 
words to say on this very interesting subject of Dr. 
Fisher's paper. It seems tome it is one difficult to discuss 
beyond endorsing the very vivid picture he has painted 
of the prevalence of syphilis and the necessity for 
doing something, and the best we can under the cir- 
cumstances. The subject, of course, is a very impor- 

1 See page 101 of tlie Journal. 

°Barr: Glasgow Medical Journal, June, 1HX9 (Archives Pediatrics, 
March, IS!»0). 



taut one owing to the prevalence of syphilis, its liability 
to spread by contagion and more than that to be 
handed down from parent to offspring. Unfortunately 
this social evil in the same way as other social evils, 
notably prostitution, is one in which the great difficulty 
which society finds in handling it, is that it is much 
easier to point out the evil and direct attention to it, 
than it is to formulate or lay down any practical means 
of overcoming it. Nevertheless the fact that we are 
not able to overcome all or even the greater part of 
these difficulties is no reason why we should not, on 
the contrary it is every reason why we should, devote 
ourselves to remedying them as far as we can ; and it 
seems to me that the suggested legislative action that 
Dr. Fisher has advocated is certainly a most excellent 
opening wedge for this very important purpose. 

He has given us a most vivid, realistic and true 
picture of the prevalence of the disease. Of course, 
the cases he sees do not represent the proportion in the 
community any more than the large proportion that I 
see in the dispensary would do the same. Neverthe- 
less in the community generally, as all general practi- 
tioners and more especially those members of the 
profession who see more or less of special practice are 
aware, the disease is very prevalent and I think with- 
out question is becoming more so of late years, although 
that is a thing that is difficult to prove. 

One point to which Dr. Fisher referred interested 
me especially, namely, the necessity of hospital accom- 
modations for cases of this sort. You commonly hear 
that there is no hospital accommodation for syphilitic 
patients. This is by no means true as the large num- 
ber that Dr. Fisher has taken care of at the almshouse 
proves, and a large number come to the dispensary for 
treatment. Beyond these a certain number do get 
into the hospitals but theoretically they have no busi- 
ness there. The truth is, however, that according to 
the rules of the large hospitals, syphilitic patients are 
not admitted ; and that for a poor person suffering 
from syphilis to get hospital treatment, it is necessary 
for him either to be sent to Tewksbury or go down to 
the Island, which latter he can't do unless he has a 
residence in Boston. The case often comes up at the 
dispensary, of men who are apparently respectable, 
who have no money and don't know what to do or where 
to go, and it is often impossible for me to suggest any- 
thing to them. Those who are lucky enough to get to 
Tewksbury or on the Island get well treated. It would 
be important to have large hospitals or other hospitals 
in the city and large ceutres where such patients could 
be properly taken care of. 

I agree with Dr. Fisher entirely that it would not 
be well to have a hospital as a simple syphilitic hospi- 
tal, or if it were so, not to call it such, as undoubtedly 
it would act very strongly against its usefulness and 
naturally we can't expect a patient if he has been un- 
fortunate or even wicked in acquiring syphilis to have 
it given to the world if it can be avoided, and that 
would prevent exactly what we wish to accomplish. 

Assuming the great advantages of hospital treatment, 
what are the reasons why it has not been heretofore 
included amongst the large and successful charities in 
which diseases of other kinds in our poor people have 
been treated? I think the first, perhaps, is the fact 
that syphilis has in connection with one other social 
evil, namely, prostitution, been treated here simply by 
being ignored, that is, the community, legislators, etc., 
wish to ignore it and that is a very poor way to treat 



Vol. CXXIII, No. 5.] BOSTON MEDIO A L AND SURGICAL JOURNAL. 



107 



it. In addition to this reason, which is no reason at 
all, there is a feeling, undoubtedly in the community, 
that a person who has syphilis has it as a result of im- 
morality, of sin, and consequently ought not to receive 
the benefits which the respectable poor should have. 
As to the Christianity or logic of that I have nothing 
to say, but even admitting that there is something in 
it there are many cases of syphilis in which that does 
not come in at all. Amongst the female patients who 
come to the service at the dispensary I am quite sure 
that over fifty per cent., are Buffering from syphilis 
without any fault of theirs at all, simply as a result of 
being wives of men who have sinned and who have ac- 
quired the disease. Certainly these women instead of 
being punished on account of their misfortune, ought to 
receive extra care and attention. Apart from that there 
are not a small number of cases of syphilis in which the 
disease was acquired without any fault, by contact 
other than that of sexual intercourse. It is not at all 
infrequent, and my only wonder is that we do not more 
often see primary lesions on the lip, where we get a 
history of drinking out of the same tumbler or smoking 
the same pipe, which somebody drank out of or smoked, 
who had the contagious lesions in the mouth. The 
mucous patches about the mouth being so very conta- 
gious, and acts of kissing, drinking out of the same 
tumbler, smoking the same pipe being so common, my 
only wonder is that more people are not infected in 
that way. Probably all of you, gentlemen, certainly 
all of you who have seen much of special practice, are 
aware of the fact that many physicians have been in- 
oculated, certainly without sin, in the practice of their 
profession. 

It might also be urged against admitting syphilitic 
patients into the hospital, that, being a contagious dis- 
ease, it would be dangerous for other patients. At the 
present day when so many diseases are claimed to be 
contagious, and when we have wards for almost all con- 
tagious diseases, that would be a reason hardly neces- 
sary to mention, but undoubtedly that has been con- 
sidered by trustees, etc., in excluding it. 

These being some of the reasons that probably have 
been urged against giving syphilitic patients hospital 
treatment what, on the other hand, can we urge for 
the necessity of so doing? 

In the first place — for the sake of the patient — I 
would put that first, although perhaps, it ought to come 
last. We all know that syphilis, especially in its early 
stages, is extremely amenable to proper treatment. 
Patients who are put under proper treatment will, in 
a comparatively short space of time, be free from con- 
tagiou and if proper treatment is continued sufficiently 
long I have no question that at the present day a great 
number of patients do throw it off entirely, whereas after 
having such treatment as a poor person would receive 
outside of a hospital, the chance of their becoming 
burdens to themselves aud to society, as Dr. Fisher 
has so graphically described, is almost certain. 

Another consideration is the removal of such persons 
from the possibility of communicating the disease to 
other people. Dr. Fisher has treated this so thoroughly 
that I will only endorse what he has said. I would men- 
tion in addition to the danger of contagion from sexual 
contact the danger of perfectly innocent contagion from 
the lips, etc. 

The proper treatment during the early stages, such 
as poor patients would get in a hospital, would be of 
the greatest importance in diminishing the chance of 



handing it down to posterity, which is, of course, one 
of the important ways in which the disease is spread. 

One of the most urgent reasons for hospital treat- 
ment, I think, is the ability that medical students and 
practitioners would have of seeing cases of this sort, 
and I think if there is any disease in which clinical 
opportunities for seeing, watching and observing cases 
is important, it is in syphilis. There is no question 
about that. Syphilis, spread abroad as it is, liable 
to crop out in all classes of the community, luckily, in 
many cases, presents appearances on the mucous mem- 
branes and skin, which to the skilled eye are distinc- 
tive. The eruption is seen, and you realize at once 
that it is syphilis. Physicians often come to me with 
a case, and say : " I can get no history." You see 
something before you, and, no matter what the history, 
you know it is syphilis as surely as you know that a 
horse is a horse. That power can only be acquired by 
seeing cases, and if the student does not see cases, and 
the practitioner, in the early part of his practice, does 
not see cases, they can't recognize it ; and one of the 
most important things in acting as a check to the 
spread of the disease is its early recognition. 

One other thing I will refer to, and that is the ex- 
pense, and the crowded condition of our hospitals, and 
the desire not to admit patients who will not be very 
nnJph benefited thereby ; but it seems to me that 
s^fmilis is just exactly one of those diseases which 
would be benefited by a stay in the hospital, more so 
than cases of cancer, phthisis, or, in fact, many dis- 
eases. If these patients could be for a few months 
or even weeks in the hospital, they would really derive 
more good for themselves, and secondarily for the 
community, than in a great many other diseases that 
are admitted without any question. 

Dr. J. C. White: Dr. Greenough has so com- 
pletely covered all the points which would occur to 
any subsequent speaker to allude to, that nothing re- 
mains to be said, I think, by myself of any great im- 
portance. I want, however, to insist upon what I 
consider to be a very important, because false, position 
which this disease holds in the community : that is the 
popular idea that there is a moral stigma necessarily 
connected with syphilis ; that it is a subject which 
should not be spoken of publicly, and should not be 
treated in our hospitals. I think that the community 
needs to be alive to this fact that syphilis is no more a 
venereal affection than some other infectious diseases, 
no more so necessarily than leprosy, that it is not in 
itself a venereal disease at all, that it has had that 
secondary character engrafted upon it simply by our 
customs of living. No doubt syphilis is, in the great 
majority of cases, conveyed from one person to an- 
other by sexual contact, but, as Dr. Greenough has 
stated, it prevails in other classes of the community 
through inherited tendencies, through contact with 
implements used in trade, the social customs of eating 
and drinking, and not by any means infrequently 
through professional handling of patients. I have 
kept a list of physicians whom I have seen directly or 
indirectly as patients, with syphilis thus acquired in 
the past few years, and their number is astonishingly 
large. The mortality in our own profession from such 
forms of syphilis is not inconsiderable in the last ten 
years. If we go into communities of a lower civiliza- 
tion we find that syphilis is often conveyed in other 
than venereal ways ; and I think that syphilis should 
be regarded as leprosy is regarded by publio enact- 



108 



BOSTON MEDICAL AND SURGICAL JOURNAL. 



[July 31, 1890. 



raent and by the community. If a leper comes to this 
port, the newspapers are full of it. He is looked at 
through a glass case ; nobody wants to touch him or 
go on the same steamer with him. It is no more dan- 
gerous for a leper to come to Boston, to any hospital 
in this city, to this room, than a case of syphilis ; and 
there is no more danger of infection ; it is not in any 
way so dangerous to the community, as a whole, as is a 
case of syphilis, and the public should be made to un- 
derstand this. If we go to a nation where the social 
habits are different, we see how syphilis may take on 
the course of infection and spread as some other non- 
venereal diseases do. If we go to a virgin soil, as 
leprosy went to the Sandwich Islands, there, owing to 
the peculiar customs, we find leprosy spreading as an 
endemic, and affecting a very large percentage of the 
people. So syphilis, in the history of these Islands, 
had a similar course. Of course the dissolute manners 
of those people made this all the more easily communi- 
cable from one person to another ; but the same habits 
of living in other ways, the dipping of the finger into 
the dish of poi, passing around the same social glass 
in a large company, the use of the pipe passed from 
one mouth to another, the same intimate habits of 
living in close contact, and sleeping in close contact, 
acted precisely to spread syphilis for the first time 
among these Islanders, as they later acted to spread 
leprosy among them. It is essential that people should 
understand that syphilis and leprosy are exactly on 
the same plane ; that one is no more necessarily im- 
moral than the other, that one is just as dangerous as 
the other, aud that syphilis is far more dangerous in 
this community, stalking, as it does, without any means 
of restraining it, than leprosy is at present in the 
United States, or is likely to be. 

Now the only way to eradicate syphilis is to treat it, 
and to treat it in its beginning. Next, to isolate it as 
far as possible by such enactments, which may work a 
little way, as Dr. Fisher has here presented to-night. 
The public should understand that syphilis is dangerous 
to the individual. It is dangerous because it produces 
the gravest results to him often in spite of treatment, 
for it is a most insidious affection ; that it is, at times, 
with great difficulty recognized, except by experts ; 
that it is of the utmost importance that medical men 
should, as Dr. Greenough has stated, have every op- 
portunity to learn to recognize it, far more than many 
other affections to which they have so much of their 
time devoted ; that trustees of hospitals and managers 
of medical schools do not do their whole duty, if they 
continue to exercise the present narrow selection of 
cases for admission to hospitals. They say, virtually, 
a student shall be allowed in this hospital to recognize 
a case of fracture or rheumatism, which is confined to 
that individual in one case alone, but he shall not have 
the opportunity of learning to recognize one of the 
most dangerous diseases which exists in this com- 
munity. They say to the medical students of New 
England : " You shall not have that opportunity," and 
they should be held responsible for it. It should be 
known to them, as to the community, that syphilis is 
dangerous, not only to the individual, but dangerous 
to his family immediately living with him, dangerous to 
his descendants, dangerous to the community at large. 

Dit. Dukgin: There is very little that I can add to 
what has already been said. The paper is a very 
pleasing one, and the remarks have covered the ground 
very completely. I think that it is a fact that the 



community is very ignorant as to the extent and 
nature of syphilis. In the first place, those who 
recognize the disease and know anything about it 
say very little; the cases are never reported. They 
are treated quietly, not taken into the hospitals, be- 
cause nobody wants to come in contact with them, and 
therefore the community is left ignorant both as to its 
extent and dangers. It has been wisely said by Dr. 
White, that this disease is more dangerous than lep- 
rosy. It seems to me so, and for one reason which 
has not been mentioned, that is, that a case of leprosy 
frightens every one, and an}' family in which a case of 
leprosy occurs is made fully aware of its dangers, and 
will take good care in handling it, but with syphilis 
I do not think that this is the case. In most families 
syphilis might occur, and the rest of the family remain 
perfectly ignorant of the fact. When they become 
aware of it, they don't understand the contagious na- 
ture of it, and the exposure is very much greater than 
in a case of leprosy. The fact that it is not taken 
into the hospitals is to be regretted. It seems to me 
that cases of syphilis could be treated in any of our 
hospitals without danger to the other inmates. With 
the present knowledge in the care of contagious dis- 
eases, it seems to me that this one might be treated as 
safely as any of the others, the danger not being 
through the atmosphere, but requiring contact. It 
seems to me that clothing, etc., which might become 
infected, could be so completely cared for as to avoid 
any spread of the disease. I don't see why syphilis 
should not be treated in any of our public hospitals. 
Not many years ago, a case of syphilis was reported to 
the Board of Health, and we were appealed to, to take 
charge of the case, which seemed to be a very bad 
one, and seemed to endanger other inmates of the 
house. We had determined to take charge of this 
case and send it to a hospital, but, on examining it, it 
did not prove to be one of syphilis. There have been 
two such cases within a few years. I felt disappointed 
at the time in not finding them to be cases of syphilis, 
hoping that we might take the initiative, and see how 
far the act would be approved by the public. I am 
very glad that this movement has started in the pro- 
fession, and I am inclined to think that if the matter 
should be properly managed before a committee of the 
legislature, that favorable action might be secured. 

Dr. Wigglesworth said: Specialization is the 
guage of progress in civilization. The savage relied 
upon himself for everything and the results were of 
the rudest description. To-day it takes eleven men to 
make a pin, but how perfect the finished product ! 

(1) The civilization of to-day demands special hospi- 
tals or, where that is impossible, special wards in 
general hospitals, for each special division of medical 
practice. Some exist already, but professional jealousy 
and ignorance of the amount already accomplished in 
the direction of the treatment of diseases of the skin, 
have thus far prevented dermatological hospitals or 
even wards. Another drawback has been the gross 
ignorance which, founding its classification upon a 
physical localization rather than upon a pathological 
basis, lumped together the most dissimilar morbid pro- 
cesses under the general head of "venereal" diseases; 
and, of course, a ward could hardly be devoted to a 
branch of medicine and cases of general, external, con- 
stitutional, chronic sy philodermata and their sequahe, 
and at the same time to a branch of special surgery 
with its cases of internal, non-constitutional, acutely 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



109 



inflammatory maladies. We cannot base a medical 
classification upon the fact of the greater relative fre- 
quency of one of the many means of infection by dif- 
ferent poisons. The poisons remain as distinct as the 
Kohinoorand a koprolite though both should be carried 
upon the same charger. I have known the kick of a 
horse to produce deafness in one case and a broken 
leg in another. We would hardly class these conditions 
together medically on account of their origin. The 
status of our profession to-day demands, I repeat, 
special hospitals or wards, at least, for both diseases of 
the skin and for geuuo-urinary surgery, the; two to be 
kept most thoroughly distinct, if only as a means of 
overthrowing old superstitions and errors. 

(2) Again ; the civic dignity of our municipality de- 
mands that she shall not be left in the extreme rear of 
scientific and humanitarian progress. Boston is to-day 
perhaps, the only civilized city of any importance, 
absolutely without special hospitals or wards for skin 
diseases. As long ago as 1873 I had the curiosity to 
look up the condition of Italian cities in this respect. 
I found that Florence (population 120,000) and Rome 
(population 210,000) had special professorships and 
clinics for diseases of the skin and syphilis. Bologna 
(population 90,000), Naples (500,000), Palmero (pop- 
ulation 170,000), Turin (population 185,000) and 
others, had each a professor and a clinic for these de- 
partments. According to sanitary regulations, enacted 
since the unification of Italy, the largest cities must 
possess special hospitals (syphilicomia), smaller ones 
special wards in their general hospitals. By law no im- 
pecunious syphilitic patient could be refused admittance. 
I selected Italy because Germany and France were 
well-known to pay almost excessive attention to these 
branches. Now remember this was the condition of 
small Italian cities nearly twenty years ago. What is 
the condition to-day of the "Modern Athens of Amer- 
ica " withits nearly half a million inhabitants and after 
the example set it by Europe for, at least, a quarter of 
a century ? Not one hospital, nor even one ward, for 
skin diseases and syphilis ! and like the rude Carthu- 
sian boor it even shuts its hospital doors against the 
houseless stranger and sends him away to disseminate 
his infection throughout the community. Five years 
ago I took occasion to investigate the condition of other 
American cities in this respect. New York had a 
skin and cancer hospital, and two wards for skin dis- 
eases at the Charity Hospital, to say nothing of the 
wards for syphilis on Blackwell's Island. Philadelphia 
had a ward for skin diseases at the University Hospi- 
tal, one at the Philadelphia Policlinic, and one at the 
City Hospital. Chicago took cases into both the 
Presbyterian and the Michael Reese Hospitals. 

(3) And now in conclusion : — the object of hospi- 
tals, I take it, is the relief of suffering, the protection 
of the community, and the instruction of the profession. 
For all these reasons special wards and even hospitals 
are demanded. Why should small-pox, a comparatively 
slight disease, running a speedy course, preventable by 
vaccination or, if present, easily recognized and avoided, 
arrogate to itself an exclusive domicile; and the great 
pox be left absolutely houseless to run a course of,, at 
least, three years, a course of steadily increasing 
intensity and yet, as a rule, unsuspected by those ex- 
posed to its infection? Why should leprosy have its 
special hospitals and these very hospitals even be iso- 
lated from inhabited places, and syphilis receive no 
attention although a precisely similar disease, due, 



like leprosy, to a bacillus, propagated in the same way 
by inoculation, but with vastly greater ease, and en- 
tailing results exactly as bad in all respects as those of 
leprosy ? The only difference is that syphilis is curable 
and, as a rule, easily cured, with proper treatment. 
All the more reason, therefore, for giving to the patient 
this proper treatment! Syphilis is more readily com- 
municated than leprosy. All the more reason for 
protecting the community by the seclusion of the in- 
fected patient! Syphilis is furthermore one of the 
easiest diseases to cure, with proper treatment on the 
part of the physician. All the more reason for giving 
both physicians and students the opportunity to learn 
in what this proper treatment consists, as well as to 
make a right diagnosis, upon which so often depends 
the moral and mental, as well as the physical welfare, 
not merely of the patient, but of his whole family. 
No ! the question is not, " Ought we have special 
wards and hospitals ? " but, How is it possible that hos- 
pital boards have so long dared to delay to furnish 
them? Their injustice is explained, not excused, by 
ignorance. But what shall be said of their medical 

m 

advisers? Has not the community a right to demand 
whether it is merely ignorance upon our part or 
whether there may not be a deeper motive ; whether 
it is a lethargic indifference to the rights of humanity 
aud to scientific progress or an active interest in means 
for our own personal advantage ? 

To avoid the possibility of such a reproach, it be- 
hooves us, as physicians, to strengthen by all means in 
our power every influence which can be brought to 
bear upon those in whose hands it lies to establish 
special hospitals or wards. According to the last 
report of the Trustees of the Boston City Hospital, 
" Suggestions and recommendations have been made 
from time to time, to the trustees, by the medical and 
surgical staff, that wards be set aside for the exclusive 
treatment of patients by the special departments. 
Such recommendations seem to be in accordance with 
the tendencies of the times aud the progress of medi- 
cal science. Diseases of the eye, of the skin, of the 
throat, of women, can undoubtedly be better treated 
in wards especially adapted for their purposes ; and the 
trustees would gladly assist in such further classifica- 
tions and special treatment, were there wards enough. 

. . . The death-rate from ' contagious ' diseases will 
remain inexcusably high, in comparison with other 
large communities, especially abroad, until our commu- 
nity shall better appreciate what is done elsewhere, 
better comprehend the dangers of contact, and until 
the city is able and willing to pay for the best means 
and methods." The people have the power ; we must 
educate them to use that power properly. 

Dr. McCollom : There has been so much said, 
and so well said, that I do not think I can add any- 
thing to the remarks that have been made. I was 
very much struck by one of Dr. Fisher's remarks with 
reference to the discharge of patients from the various 
institutions. It frequently happens that men or women 
who are suffering from syphilis will be discharged from 
the jail. There is no power to control it. They are 
advised to go to the dispensary or to Tewksbury. In 
some cases they do so ; in other cases they do not. 
Of course, this question is an important one, and it is 
a question which the profession should take hold of in 
earnest. Much can be done by proper legislation ; but 

1 think even more can be done by the efforts of indi- 
vidual physicians in educating their patients up to the 



110 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 31, 1890. 



fact that syphilis is so contagious. A comparatively 
small number of patients have any idea of the conta- 
giousness of syphilis. They should also be instructed 
as to the importance of continuing treatment a very 
long time. The majority of patients stop treatment 
too early, and, as a result, are not properly treated ; 
and they do not resume treatment until something 
new manifests itself. Hence the importance of a de- 
partment in our hospitals for skin diseases and for 
syphilis is very great. 

Dr. P. C. Knapp : I want to add just a word with 
reference to the comparison which has been made here 
a number of times between leprosy and syphilis. 
There is one point which, it seems to me, has been 
forgotten, that is, that when leprosy attacks a patient, 
it kills him eventually ; when syphilis attacks a pa- 
tient, the patient is cured in a few years, and then, five 
or ten or twenty-five years later, he or she comes down 
with tabes, with an attack of hemiplegia, or with gen- 
eral paralysis or some other of the late nervous mani- 
festations, which, if not due directly to syphilis, are 
vastly more frequent in syphilitic subjects than in per- 
sons who have never had syphilis. That, it seems to 
me, is a thing that should be borne in mind, and should 
emphasize what the dermatologists have had to say to- 
night in regard to the necessity for some effort to 
check the spread of syphilis. 

Dr. J. C. White made the following motion : 

Voted, That the Section of Clinical Medicine, of the 
Suffolk District Medical Society, earnestly asks the 
attention of the managers of the Massachusetts Gen- 
eral and City Hospitals to the subject of hospital ac- 
commodation for syphilitic patients, and expresses its 
conviction of the pressing importance of such provi- 
sion in the institutions under their charge. 

The motion was passed unanimously, and the Secre- 
tary was directed to transmit the vote of the Society 
to the Trustees of the Massachusetts General and Bos 
ton City Hospitals. 

Dr. C. Irving Fisher presented the following sug- 
gestion for legislative consideration : 

An Act to prevent the spread of syphilis by criminals 
and paupers. 

Be it enacted, etc., as follows: That any inmate of any 
criminal or public charitable institution, who has syphilis, 
shall at once be placed under medical observation and 
treatment, and shall not be discharged therefrom until 
three months after all infectious symptoms have disap- 
peared. 

This Act shall not be construed to apply to any institu- 
tion supported by private charity. 

The vote of the meeting was taken, and it was in 
entire approval of the above suggestion, and a commit- 
tee of three was appointed to take action thereon. The 
Chairman named Drs. C. Irving Fisher, J. C. White 
and F. 15. Greenough as that committee. 

Adjourned at 10.30 o'clock. 

— A preliminary meeting of the incorporators of 
the proposed Rush Hospital for consumptives in Phila- 
delphia, has been held. The list includes many of the 
well-known names in Philadelphia medical circles. A 
location in West Philadelphia is under consideration. 

— A moderate epidemic of typhoid fever has occurred 
at Princeton, N. J., which, if we are to believe press 
reports, has been traced, like the recent one at Water- 
bury, Couu., to a milk supply. 



AMERICAN OTOLOGIC AL SOCIETY. 

Twenty-third Annual Meeting, held at Hotel 
Kaaterskill, N. Y., July 15, 1890. 

MORNING SESSION. 

President Dr. Oren D. Pomeroy, of New York, 
in the chair. 

The first paper was entitled 

MASTOID SCLEROSIS, AS ILLUSTRATED BY A TYPI- 
CAL AND FATAL CASE, 

by Dr. Huntington Richards, of New York. 

The patient, a man aged twenty-six, came under 
observation March 8, 1890. Eleven mouths before a 
large polypus had been removed from the left auditory 
canal. The symptoms noted March 8th were earache 
and headache, with some mastoid tenderness. There 
was apparently a cicatricial drum membrane greatly 
depressed. There was an opening in it about three 
millimetres in diameter. A small polypus projected 
through the opening. A dose of calomel was ordered, 
and Bacon's artificial leech, followed by frequent 
douching, was advised. It was at this time deemed 
probable that an operation on the mastoid would be 
required. Four days later the drum membrane had 
become prominent. A Politzer inflation greatly in- 
creased the prominence. There was no redness or 
stenosis of the wall of the auditory canal. The drum 
membrane was adherent to structure posterior by a 
line along its middle, dividing the prominence into two 
portions. Three days later a portion of one of these 
prominences was removed by the snare. Three days 
later (18th) the auditory canal was much stenozed. 
There was swelling and tenderness in front of the ear, 
and some tenderness over the mastoid lip. The artifi- 
cial leech was again applied with benefit. May 1st a 
polypus that had formed was removed. May 3d there 
was again mastoid tenderness. Discharge became 
profuse. May 5th the mastoid was operated on, but no 
trace of pus or of any true antrum was found. May 
10th the temperature rose to 104.2° F.,and the patient 
complained of violent headache. May 12th the at- 
tempt was made to extend the opening forward to- 
wards the tympanum by the use of Volkmann's spoon, 
without result. The opening was then enlarged by 
chisel and rongeur forceps until it became funnel- 
shaped, measuring twenty-seven millimetres in depth 
and twenty-seven by twenty millimetres in width. No 
antrum was discovered and no recognizable drum- 
cavity was opened and no accumulation of pus tapped. 
The day following the operation muttering delirium 
set in with diplopia, some slight convulsive move- 
ments of the orbital aud facial muscles, complete ptosis 
of the left eyelid, and persistent tonic contraction of 
the muscles of the right side of the neck. The patient 
continued to fail, and died at 4.30 p.m. unquestionably 
of diffuse meningitis, and not improbably there was an 
inter-cranial abscess. No post-mortem could be ob- 
tained. It is possible, though far from certain, that 
an early and thorough operation for removal of the 
ossicle and pus-confining membrane would have accom- 
plished what the two mastoid operations failed to do, 
namely, adequate outlet for pus, etc., and consequent 
saving of life. 

In Ins paper the author urged the adoption of the 
expression " vault of the tympanum " or " fornix tym- 
pani " to designate that portion of the drum-cavity 
above the upper border of the tympanic ring. This 



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Ill 



term is quite as appropriate as is the half facetious 
though conveniently brief "attic" of several recent 
writers. As to a supposed and most erroneously sup- 
posed Latin equivalent of the latter, namely, '"atticus," 
it is hardly necessary to say that it is wholly inadmissi- 
ble on linguistic grounds, there being no noun " atti- 
cus" in the Latin language, save the adjectival sub- 
stantive used to designate an Athenian citizen. " At- 
ticus " is not, never was and cannot now be, made the 
Latin term for a garret, attic or upper story of a house. 
Dr. S. Theobald, of Baltimore, reported 

A CASE IN WHICH A SEPTUM CLOSELY RESEMBLING 
THE TYMPANUM MEMBRANE FORMED JN THE MID- 
DLE THIRD OF THE EXTERNAL AUDITORY CANAL, 
AND WAS REMOVED WITH IMPROVEMENT TO 
HEARING. 

The septum, which was present only in the right 
ear, was about six millimetres nearer the outer ex- 
tremity of the auditory canal than was the tympanal 
membrane of the opposite ear. It evidently had no 
connection with the ossicle, but moved out when the 
middle ear was inflated by the Valsalva method, and 
moved in again during the act of swallowing. There 
was a history of double otorrhoca in childhood. After 
excision of the septum, it was found that the tympanal 
membrane proper was entirely destroyed, but the 
stapes and malleus were recognized in situ. The mu- 
cous membrane of the tympanal cavity was sclerosed 
and atrophied. A marked improvement of hearing 
followed immediately upon the removal of the septum. 
Further improvement was subsequently gained by in- 
serting an artificial (cotton) drumhead. The hearing, 
which before the operation was equal to distinguishing 
words in a loud voice at twenty feet, was improved to 
words in a low voice and whisper at twenty feet. The 
septum showed a decided tendency to reformation, 
which had to be controlled by the application of chro- 
mic acid and a second resort to the knife. 

The President : These membrames forming in 
the external canal have for their end a reparative ac- 
tiou. 1 saw such a membrane form in a case of my 
own, where there had been otorrhoea, with loss of 
most of the membrane for fifteen years. The dis- 
charge ceased under treatment, and there was the 
formation of a new membrane similar to that described 
by Dr. Theobald, only in my case it was much thicker. 
I consider that in most cases the formation of this 
membrane is a most satisfactory reparative result. I 
should be glad to see Dr. Theobald's case followed for 
some time, to see whether or not there was any return 
of disagreeable otorrhoea. 

Dr. J. A. Andrews, of New York: A few years 
ago I reported to the Society a case similar to that of 
Dr. Theobald. The membrane closed about three- 
fourths of the canal. It was removed, and there was 
no return of the discharge. 

Dr. Huntington Richards, of New York : i 
recently saw a case in which there were two closures, 
one at nearly the normal distance of the tympanic 
membrane, and the other close to the meatus. I re- 
moved the outside membrane, but hesitated to cut 
through the other, as in one or two cases where I have 
done so the evidences of improvement have not been 
great. I am now treating a similar case, where the 
stenosis is close to the position of the normal tympanic 
ring. I have cut away the lower portion of the ring 
with acetic acid to permit free exit of discharge. 



Dr. Theobald, of Baltimore: There was no re- 
turn of the discharge in the few weeks that the patient 
remained under observation. The patient would un- 
doubtedly have been willing to be more or less troubled 
with otorrhoea to gain the marked improvement in 
hearing. 

on the renewed employment of the nasai. 
douche and kindred procedures, 

by Dr. A. H. Buck, of New York. 

Several years ago attention was called to the dan- 
ger of exciting ear trouble by the use of the nasal 
douche and similar procedures. For some time it 
seemed that this warning had been heeded. During 
the past winter and spring the author had seen a large 
number of these cases, and thought it advisable to 
again call attention to the dangers that may follow 
the use of the nasal douche. In a few instances the 
results of the inflammation have been severe, but in 
the majority they have been simply an increase of the 
subacute nasal and aural catarrh. 

As a safer and equally efficient method of treatment 
the use of a spray was suggested. The following 
preparations were mentioned : 

ii Eucalyptol. 

01. Gaultheria . , . . aa gr. j. 

Menthol gr. ij. 

Benzoinol 3 ij- M. 

If the patient objects to this, it may be substituted 

by 

K- Listerine 1 part. 

Water 3 parts. 

In the presence of an accumulation of viscid mucus 
or of crusts, a stream of flowing water will doubtless 
prove more effective than a stimulating spray. If the 
latter is used freely and each time during the inhala- 
tion of a deep breath, crusts and mucus will speedily 
cease to play a part in the therapeutic problem. In 
no instance had he known the use of the mixtures 
mentioned to cause any unpleasant aural symptoms. 
The use of sprays must, however, be looked upon only 
as a valuable method of supplementary treatment, and 
not as a therapeutic procedure of the first order. 

THE REMOVAL OF A BULLET FROM THE EAR, WITH 
THE ASSISTANCE OF THE GALVANO-CAUTERY, 

by Dr. Lucien Howe, Buffalo. 

The difficulty occasionally met with in removing a 
round, hard body from the auditory canal is well 
known. The first efforts in these cases should be 
made with a syringe. The writer wished in this 
paper to call attention to a method which may occa- 
sionally prove useful, and which, so far as he was 
aware, had not been before suggested. 

April 30th, a boy seven years old was brought to 
him with a small bullet lodged in the lower part of the 
auditory canal. An attempt to remove it by syring- 
ing was first made, without avail. An attempt with 
forceps showed the foreign body firmly imbedded, and 
on account of its smooth surface, it was impossible to 
grasp it. It then occurred to the operator that it 
might be possible to melt into the lead the wire of a 
galvano-cautery, by means of which, when cool, it 
could be removed, or, if not, to at least roughen the 
surface to such an extent as to allow forceps to grasp 
the bullet firmly. The child was put under the influ- 
ence of chloroform, and the wire was melted into the 
lead, aud the ball was drawn to the narrow part of the 



112 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 31, 1890. 



canal, where it became detached. The surface of the 
bullet was then roughened above and below, and with 
toothed forceps removed. 

The speaker took the opportunity offered by the re- 
port of this case to express his firm conviction that we 
should use ever}' effort to discourage the practice com- 
mon among physicians of attacking every such foreign 
substance with a pair of forceps. By our own example 
and discussion, we should teach our brother practition- 
ers how much simpler and safer an instrument we have 
in the syringe. 

Dr. A. H. Buck, New York, made a supplemen- 
tary report on the 

ANATOMY OF THE ELEPHANT'S EAR. 

Dr. C. H. Burnett, of Philadelphia, read a paper 

on 

permanently good results of excision of the 
malleus and membrana tympani, in a case 
OF chronic tinnitus and aural vertigo, and 
in a case of chronic suppuration of the 
attic due to necrosis of the head of the 

MALLEUS. 

In the first case, all known remedies for the relief of 
catarrhal deafness, tinnitus aurium and vertigo failed 
to give any relief. The malleus being found adherent 
to the promontory, this was believed to be the cause 
of the retraction of the chain of auditory ossicles, im- 
paction of the stapes, pressure on the labyrinth fluid, 
and the noises in the head, and intense aural vertigo. 
The patient was therefore etherized (May 22, 1888), 
and the membrana tympani and the malleus excised. 
The relief to the tinnitus and vertigo was instantane- 
ous and complete, and the cure has been a permanent 
one for two years, thus proving the mechanical origin 
of so-called Meniere's disease in many instances. 

In the second chronic purulent discharge 

from the attic cavity of the middle ear, due to necrosis 
of the head of the malleus of several years' duration, 
was promptly and entirely relieved by excision of the 
membrana tympani and the diseased malleus. The 
operation was performed in July, 1889. The purulent 
discharge ceased at once. A new membrana formed 
in the course of two months, aud the hearing rose from 
nothing to twelve feet, for isolated words. There has 
been no renewal of the discharge up to the present 
time, one year from the date of operation, and the 
general health of the patient has greatly improved. 

Dr. B. Alexander Randall, Philadelphia, con- 
tributed further notes on 

THE SHARPNELL PERFORATION. 

He remarked that in citing in his paper of the pre- 
vious year, a series of 13 new cases among 500 patients 
in six months' practice and a total of 120 among 10,000 
in a group of clinical workers, he had thought the fre- 
quency of the lesion sufficiently proven ; yet, as the 
point had been questioned when his paper appeared, 
lie had been noting such cases again since January 1st, 
As the result, he had 23 cases to report, observed 
among 500 new patients of the six months, three of 
which occurred in patients previously seen, but with- 
out recognition of such a perforation. His incomplete 
notes for the latter half of 1889 showed only four 
records of the lesion, btit he was confident that many 
more had been seen and treated. Yet, even accepting 
this record as complete, it furnished a series of 27 



cases among about 1,000; or 42 among the 1,500 
patients seen during h'fteeu months = 2.8%. 

Excision of the drum membrane and malleus had 
been done in two of the cases before reported, without 
any such brilliant result as to lead him to prefer this 
radical measure to the iutra-tympanic syringing usually 
emplpyed. He expected to adhere to the latter using 
as before the Anuel syringe and the hollow lachrymal 
probe as the most satisfactory apparatus, and the per- 
oxide of hydrogen and weak solutions of the mineral 
acids as the fluids. 

The cases were reported in detail, with drawings of 
many of them, aud the farther history of the former 
cases was appended. 

Dr. J. A. Lippincott, of Pittsburgh, reported a 
case of 

MASTOIDITES INTERNA PURCLENTA FOLLOWING ERY- 
SIPELAS. 

The ear became involved one week after the occur- 
rence of a severe attack of erysipelas. There was no 
preliminary involvement of the throat or nose. The 
patient recovered after opening of the mastoid and 
syringing. 

Dr. Neil J. Hepburn, of New York, reported a 

case of 

FRACTURE OF THE MALLEUS HANDLE FROM THE 
INTRODUCTION OF A HAIR-PIN. 

SOME CASES OF MASTOID CELL DISEASE WITH A 
FISTDLOUS OPENING WHICH RECOVERED WITHOUT 
THE USE OF THE DRILL OR CHISEL, 

by Dr. Oren D. Pomeroy, New York. 

Four cases were reported in which recovery oc- 
curred by the use of Wilde's incision aud careful 
antisepsis : 

The first case was that of a woman, forty-nine years 
of age, who had a fistulous opening into the mastoid 
three-fourths of an inch deep. After waiting a rea- 
sonable time for the fistula to close from the bottom, 
the external wound was allowed to close. There was 
no untoward results. 

The second case was that of a man, thirty-nine years 
of age, who had a fistula into the mastoid eleven-six- 
teenths of an inch deep, which healed before the 
external wound was closed. 

The third case was that of a child, four months of 
age, who had an opening into the mastoid, extending 
forwards and inwards for one and a half inches. This 
had nearly closed, when the external wound was 
allowed to close. 

The fourth case was that of a man, twenty-two 
years of age, who had an opening into the apex of the 
mastoid, which closed concurrently with the Wilde's 
incision. 

None of these cases had enough systemic disturb- 
ance to suggest that anything was going wrong. 

ANEURISM FIRST RECOGNIZED IN THE FUNDUS OK 
THE EAR, LATER APPEARING IN THE NECK, 

by Dr. Charles A. Todd, St. Louis. 

May, 1880. Mr. C, forty-five years of age, came 
under observation complaining of pain in the left ear 
and symptoms suggesting furuncles. In 1858, he had 
severe otitis media in both ears for one week, followed 
by discharge which ceased without treatment. Some 
deafness has since existed. For the past seven or 
eight years he had noticed a pulsating sound, at first in 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



113 



both ears, now in the loft. On examination of the left 
ear, there was seen a circumscribed swelling on the 
floor of the meatus just in front of the membrana and 
entirely concealing it. It was soft and fluctuating. 
Killing the ear with water a distinct intra-aural pulsa- 
tion could be seen. The swelling was lanced under 
the supposition that it was a furuncle. There was a 
free gush of blood and some three ounces of blood 
were lost before the flow could be stopped by tampon- 
ing. No pus whatever was seen. The tampon could 
not be permanently removed for several days. Com- 
pression by tampon was advised to be continued at 
home. August, 1880, it was learned that compression 
had afforded little benefit. Ligation of common caro- 
tid was suggested if symptoms were considered sufli- 
ciently severe. 

March, 1883, patient was again seen. Electrolysis 
had been tried with asserted diminution in size. March, 
1890, the aural tumor was still present, but in addition 
there was a large aneurismal swelling of the neck below 
the ear. The patient was then referred to a general 
surgeon and has not since been heard from. 

dr. blake's paper disk: case histories, 

by Dr. Robert Barclay, St. Louis. 

The object of the paper was particularly to call 
attention to the application of paper dressings to the 
membrana tympani, first suggested by Dr. Clarence J. 
Blake of Boston, for the treatment of perforations of 
that structure. To demonstrate not only the advantages 
claimed for this method, but others modestly disclaimed, 
and its wide usefulness in other conditions than those 
defined for its applications when originally suggested, 
the following cases were reported: 

Case I. A lady twenty-eight years of age, with 
right-sided acute otitis media of twenty-four hours' 
duration. The right membrana tympani vibrana was 
found bulging. A deep incision afforded some relief. 
At the end of five days a perforation of the posterior 
superior quadrant of the membrana tympani. This 
was closed by the application of a pa,per disk. Seven 
weeks later the disk with attached epithelial plate was 
removed from the superior posterior canal wall. The 
perforation had healed and hearing was normal. 

Case II. A lady twenty-one years of age, sought 
relief from tinnitus and deafness of right ear. The 
left ear had been condemned as irreparably disabled 
by former inflammation. She had had otorrhcea in 
childhood. Three years before, there had been a 
return of this trouble in the left ear. This was checked 
after one week's duration. This ear, however, remained 
deaf. With the right ear she could hear a moderate 
voice, with the left, a loud voice at two feet. Right 
middle-ear was the seat of chronic catarrhal inflamma- 
tion. The membrana tympani of the left ear was 
perforated in the posterior inferior quadrant. Treat- 
ment somewhat relieved the symptoms in the right 
ear. Stimulating applications to the perforation in- 
duced its closure to one-sixteenth in diameter, when a 
paper disk was applied. Two days afterward the disk 
was still in place. Hearing in left ear was one-forty- 
eighth ; while moderately loud voice could be heard at 
twenty-five feet distance. The disk was subsequently 
removed and the perforation closed. The hearing of 
left ear has steadily improved. 

Case III. A man thirty-five years of age, was seen 
with deafness, tinnitus, cough and otorrhcea in left ear 
of two months' duration. Two circular perforations of 



membrana tympani were found. The otorrhea was 
checked and a paper disk applied to each perforation 
with immediate improvement of hearing for the voice. 
It is thought that the relief may have been permanent 
as the patient did not return. 

Case IV. A woman thirty-seven years of age. 
Six weeks before coming under observation sustained 
a compound fracture of the skull involving both sides 
of the base, the bony tympana, membranal tympanum 
and right external auditory canal. There had been 
aural hajmorrhage followed by otorrhcea. There was 
a transverse rent of right membrana. Within thirty- 
live days the only open wound was a small perforation. 
A paper disk was applied, a little flexible collodion 
was painted over it. Within two weeks hearing be- 
came normal. 

Case V. A lady twenty-one years of age, with the 
left membrane almost entirely sloughed away. A 
paper disk was applied. Within twenty days the watch 
could be easily heard off the left auricle. The hearing 
has steadily improved. 

Case VI. A man twenty-two years of age, had 
prolonged otorrhcea on right side in childhood. For 
past three weeks had deafness in both ears. Left ear 
was the seat of chronic catarrhal otitis media. Right 
ear shows two perforations. These closed in seven 
weeks. There was marked improvement of the hear- 
ing. 

Case VII. A youth nineteen years of age, had 
been subject to bilateral otorrhoea since the age of six 
months. Perforation of right membrana tympani was 
found. After cessation of otorrhcea, paper disks were 
applied. The perforation promptly closed with im- 
provement of hearing. 

Case VIII. A man nineteen years of age, had 
otorrhoea in childhood. During past eight years has 
had recurring attacks of otorrhcea on left side. The 
left membrana tympani was greatly thickened and per- 
forated. The discharge ceased in nine days and under 
stimulating treatment the size of the opening diminished. 
In the fourth week the first paper disk was applied. 
Four days later the hearing for the watch was |f. 
The perforation has subsequently closed. 

Case IX. A physician, forty-eight years of age, 
had sustained a rupture of both tympanic membranes 
in diving thirty-four years before and for over thirty 
years had intermittent otorrhcea. A perforation in 
the right membrana tympani was found. This promptly 
healed under the application of a paper disk. The 
hearing greatty improved. 

Conclusions : From the case histories given may it 
not be considered demonstrated that Dr. Blake's paper 
dressings have these therapeutic advantages already 
claimed ; applied to a perforation of the membrana 
tympani, it performs in a great measure, the functions 
of the lost membrane, (1) improving the hearing from 
the time of application, (2) maintaining a normal 
degree of moisture and temperature in the air of the 
tympanic cavity, (3) protecting the enclosed tissues 
from direct influence to atmospheric influences, and (4) 
excluding organic and inorganic foreign bodies approach- 
ing from the external auditory canal, (5) it acts as a 
local irritant to the edge of the perforation only, 
thereby inducing reproduction of the lost membrane, 
(6) as a splint protecting it when formiug and prevent- 
ing its displacement in either direction. 

May we not accredit this method with these addi- 
tional advantages hitherto unclaimed : (1) Improve- 



114 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 81, 1890. 



ment iu hearing may subsequently result from cicatri- 
cial closure of the perforation, not at once appreciable 
on application of the paper disk ; (2) the paper dress- 
ing may prove servicable even where the perforation 
is quite large; (3) it may be used to advantage where 
indeed the outer surface of the membrana tympaui has 
not returned to its normal condition ; (4) it may prove 
a servicable artificial membrana tympani where that 
structure is almost entirely lost ; (5) at the same time 
may stimulate reproduction thereof ; (6) it may serve 
as a splint when applied to manometric tissue; (7) it 
may induce conservative structural modification thereof 
and (8) may by acting here as an artificial membrana 
tympaui at the same time improve the hearing. 

A failure to secure satisfactory results is not to be 
attributed to the method, experience proving that dis- 
criminating judgment and skill in its application are 
largely essential to its usefulness. 

The following officers were elected : President, Dr. 
Gorham Bacon, New York ; Vice-President, Dr. 
Huntington Richards, New York ; Secretary and Treas- 
urer, Dr. J. J. B. Vermyne, New Bedford, Mass. ; 
Committee on Membership, Drs. Arthur Matthewson, 
Brooklyn ; Samuel Theobald, Baltimore, and S. D. Ris- 
ley, Philadelphia ; Committee on Publication, Drs. J. J. 
B. Vermyne, New Bedford ; C. J. Blake, Boston, and 
J. Orne Green, Boston. 

The following were elected to membership : Dr. 
Frederick L. Jack, of Boston ; Dr. J. B. Shapleigh, of 
St. Louis ; Dr. Benjamin J. Baldwin, of Montgomery, 
Ala. ; Dr. J. M. Ray, Louisville, Ky., and Dr. F. U. 
Ring, of New York. 

The Society then adjourned. 



decent Hiterature. 



The Gulstonian Lectures on Secondary Degenerations 
of the Spinal Cord. Delivered at the Royal Col- 
lege of Physicians, March, 1889, by Howard H. 
Tooth, M.D., F.R.C.P., etc. Octavo, pp. 71, with 
14 illustrations. Loudon: J. & A. Churchill. 1889. 
To the student of the fine anatomy of the spinal 
cord, this careful study is a necessity. Dr. Tooth's 
personal researches are based upon various cases of 
transverse lesion of the cord in man, and upon experi- 
ments made upon monkeys by Mr. Victor Horsley. 
In addition, however, the author has incorporated into 
these lectures many of the results reported by other 
investigators. The first lecture is devoted to the study 
of the pathological changes of degeneration. The so- 
called traumatic degeneration is essentially inflamma- 
tory, and embraces the whole region about the lesion, 
irrespective of special tracts. Secondary degeneration 
is visible in six days. Secondary degeneration iu the 
cord is due to destruction of trophic centres, interrup- 
tion in the continuity of fibres, or section of the pos- 
terior roots ; it is not the same as Walleriau degenera- 
tion of the nerves ; the fibre is rendered useless, and 
its place is gradually taken by thickened neuroglia. 
The process is usually complete in six months. In 
the peripheral nerves the fibre dies, but regeneration 
also occurs. Tooth doubts whether anything like a 
regeneration of cord fibres ever occurs. The next two 
lectures are devoted to the study of ascending and de- 
scending fibres iu the various tracts of the cord, — a 



subject of the utmost importance to our knowledge of 
anatomy and physiology. The student will find in 
this admirable presentation an admirable guide to the 
subject. Space is lacking to point out the various 
data collected, but we must call attention to the sec- 
tion on the visceral fibres of the cord, medullated fibres 
of the finest calibre, efferent and afferent, which have 
long been observed, although their significance has 
been unknown. The author calls attention once again 
to these fibres, and suggests the importance of a care- 
ful study of them in all obscure cases of nervous dis- 
turbances of the viscera. Although appealing prima- 
rily to the specialist, this monograph is one the perusal 
of which would repay every physiciau. p. c. k. 

Recherches Cliniques et Therapeutiques sur V Epilepsie, 
VHysterie et V Idiotie. Par Bourneville, Sol- 

LIER, PlLLIET, RaOULT, BrICON et COURBARIEN. 

Octavo, -T. viii, pp. lx, 263, with 27 illustrations. 

T. ix, pp. lx, 92, with 25 illustrations. Publications 

du Progres Medical, Paris. 1888, 1889. 

These two volumes sum up the work of the service 
for epileptics, idiots and feeble-minded, at Bicetre, for 
the years 1887 and 1888. The first part of each vol- 
ume is devoted to tables of statistics, an account of the 
new contagious ward, isolated ward and dormitory, 
and an illustration of some of the methods employed 
in the management and instruction of idiots. The 
second part is clinical, and contains various articles, 
based on observations at Bicetre, many of which have 
already appeared elsewhere. The most importaut of 
these is a long article, in the eighth volume, by Bourne- 
ville and Bricon, on procursive epilepsy, a form of 
epilepsy attended with rapid propulsion in a straight 
line or in a circle, seldom attended with a fall or fol- 
lowed by coma, but complicated with marked conges- 
tion of the face. The relations of these attacks to the 
procursive aura, to post-epileptic procursion and to 
automatism are pointed out. Procursion itself is 
thought to be due, as far as the few autopsies give any 
light, to some cerebellar lesion. The prognosis, as in 
all forms of epilepsy, is grave. The other most im- 
portant papers in this volume are one on two cases of 
double athetosis with imbecility by Bourneville and 
Pillier, aird one on dentition in idiots by Sollier. In 
the ninth volume, Bourneville reports another inter- 
esting case of myxoedematous idiocy, and Bourneville 
and Courbarien study the role of consanguinity of 
parents in the aetiology of epilepsy, idiocy, imbecility 
and hysteria. Their conclusions are, that healthy con- 
sanguinity has no effect, but that where the parents 
are defective, consanguinity intensifies the probability 
of defect in the offspring. p. c. k. 

A Treatise on the Science and Practice of Midwifery. 
By W. S. Playfair, M.D., LL.D. Fifth Ameri- 
can, from the Seventh English Edition, with Notes 
and Additions, by Robert P. Harris, M.D. Phil- 
adelphia : Lea Brothers & Co. 1889. 
This work is too well-known to require extended 
notice as successive editions appear. The most im- 
portant changes noted are in the sections on the Porro 
operation, on the conservative Cesarean operation, and 
on the treatment of extra-uterine pregnancy. We see 
with pleasure that the new obstetric nomenclature has 
been adopted in this edition ; but we regret that the 
distinguished author has thought best to retain the 
autogenetic theory of puerperal sepsis. 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



115 



THE BOSTON 

jHcDical auD ^utgtcal journal. 



THURSDAY, JULY 31, 1890. 



A Journal of Medicine, Surgery , and Allied Sciences, published at 
Boston, weekly, by the undersigned. 

Subscription Terms : $5.00 per year, in advance, postage paid, 
for the. United States, Canada and Mexico ; fC.56 per year for all for- 
eign countries belonging to the Postal Union. 

All communications for the Editor, and all books for review, should 
be addressed to the Editor of the lioston Medical and Surgical Journal, 
283 Washington Street, lioston. 

All letters containing business communications, or referring to the 
publication, subscription, or advertising department of this Journal, 
should be addressed tol/te undersigned. 

Remittances should be made by money-order, draft or registered 
letter, payable to 

DAMRELL & UPHAM, 
283 Washington Street, Boston, Mass. 



THE CONTROL OF SYPHILIS. 

The subject of State control of syphilis is a very 
vital one, which forces itself upon the notice of the 
profession with great emphasis. There can be no 
question that the evil has become one that deserves 
some attention at the hands of those who provide for 
the preservation of public health. The disease holds 
a singular position, in that, in common with other 
venereal diseases, it is shut out from the charity of 
our public hospitals. The exact reason for depriving 
venereal patients of hospital treatment may not neces- 
sarily have been anything more than that they were 
not considered the class upon whom public charity 
should be expended. But the conditions have changed. 
They have become a menace to the public health, and 
for self-protection some action should be taken. 

Syphilis is, however, only nominally a venereal dis- 
ease. It is the large proportion of cases of non-vene- 
real syphilis, syphilis insontium, which gives the dis- 
ease its importance. 

In discussiug the subject of State control in 1887, 
Fournier gave as the proportion of women in his private 
practice who had received the disease without wrong- 
doing on their part as nineteen per cent. This result 
was reached after throwing out all doubtful cases. Dr. 
Oreeuough, in the discussion which we publish to-day, 
puts the percentage of women innocently affected in 
his dispensary practice as more than fifty per cent. 
It must be remembered that these innocent women are 
not all even the wives of unfaithful husbands, — some 
are the wives of men who have been themselves acci- 
dentally inoculated from a common pipe or drinking- 
glass. 

Public opinion has somewhat changed iu regard to 
the charity to be bestowed upon evil-doers. It is a 
more commonly accepted idea that the regeneration of 
the sinner is most easily introduced by the care of his 
physical ills. The missionary is now also a physician, 
or is accompanied in his field of labor by a physician, 
and missionaries have been found iu the class-room 
with medical students, studying syphilis as one prelim- 



inary or assistance to their missionary work ; and 
Barely, in our own country, the day has gone by when 
syphilitica must be considered as beyond the reach of 
compassion and assistance. 

The strict regulation and control of syphilis, as is 
attempted in some foreign countries, is out of the ques- 
tion in the United States, nor is there very good rea- 
son to desire such a method. Its success is not un- 
questioned, even in the countries where the regulations 
are most strict. Some other method must be found 
here, and the first and most obvious is the establish- 
ment of hospital accommodations. There is room for 
two opinions as to the propriety of letting down the 
bars which rule it out of general hospitals. It may 
not be best to do so ; but some provision can be made, 
and is demanded for public safety. Even private char- 
ity might find a most worthy object in establishing 
suitable hospital provision for syphilitics. 

There is one method of bringing public attention to 
the evil, which ought to be put in practice. Syphilis 
might well be included iu the same quarantine regula- 
tions that exclude patients with leprosy from entering 
the country. The number thus excluded would prob- 
ably be but a tithe of the number that now annually 
enter our ports to become a burden to the commu- 
nity ; but the effect of the exclusion of a single indi- 
vidual would have a wide result for good, in deterring 
others from emigrating. 

V — 

THE INSANITY OF CARDIAC DISEASE. 

According to Bull (Medecine Moderne, No. 29, 
p. 577) mental alienation, due to disease of the heart, 
is relatively rare. 

Nasse, in 1818, first wrote of cardiac insanity as a 
special psychosis. Since then, numerous treatises have 
appeared on the subject ; notably those of St. Gerinin- 
Limbo, Astros, Duriez, Sancerotte, Norel, Armam- 
gault, etc. 

It has long been remarked that sufferers from heart 
disease occasionally present peculiar mental symptoms. 
They are emotional, irritable, peevish, get angry at 
the least trifle, while, at the same time, possessing 
great mental and bodily activity. These psychical 
peculiarities do not amount to mental alienation, but 
they constitute a tendency of mind on which insanity 
may graft itself. 

What are the two fundamental conditions necessary 
to constitute cardiac insanity ? 

First and foremost, a lesion of the heart, then a par- 
ticular disposition of the cerebrum. The cardiopathy 
is the sine qua non ; what it is important to remember 
is that the insanity generally breaks out during au 
exacerbation of the cardiac symptoms. One of Bull's 
patients felt his suicidal impulses only when the palpi- 
tations, the painful constriction of the thorax, the 
dyspnoea came on. " These accidents (the insane 
manifestations) made their appearance chiefly when 
the patient was standing, and when he was leaning his 
head forwards, thus producing ana;mia of the bulb 



116 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [July 31, 1890. 



and congestion of the frontal lobes ; they rapidly dis- 
appeared when he lay down on his back. The morbid 
impulse vanished with the respiratory distress." 

As for the particular heart-lesion, it is generally 
agreed that mitral affections are the most influential 
in bringing on this psychosis ; next in order come the 
ventricular hypertrophies, and lastly, aortic insuffi- 
ciency, a lesion which is peculiarly prone to anaemiate 
the bulb, and give rise to the anguish and dyspnoea so 
characteristic of Corrigan's disease. 

We are hardly yet in possession of the knowledge 
which might enable us to refer special kinds of insanity 
to particular kinds of lesions. Patients may be af- 
fected with all forms of cardiopathy without mental 
alienation, while the great majority of the mentally 
unsound have no lesion of the heart whatever. But 
melancholia, doubtless, oftener coincides with heart 
disease than any other psychosis. There exists a 
cardiac lypemania accompanied with a restlessness and 
an agitation which bears a marked resemblance to 
"anxious melancholia," that is, a delirium with pre- 
dominance of sad ideas, and with an exaggerated 
tendency to noisy lamentations, and an irresistible 
tendency to continued movement. 

Burman considers hypochondriac melancholia as the 
type of cardiac insanity ; to this he joins the delirium 
of suspicion, and a particular mental state in which 
the subjects are at once impulsive and depressed. 

It has been remarked that all the victims of cardiac 
insanity are extremely prone to suicide, and that the 
morbid impulse is especially apt to manifest itself on 
the occasion of an aggravation of the circulatory 
troubles. The delirium is peculiarly a delirium of 
the night time, as Corvisart has remarked. It has, 
moreover, been noted that the supervention of albu- 
minuria is one of the most important factors in the 
production of the delirium. A cardiac patient in 
the full possession of his reason will show signs of 
mental derangement, will have delirium, hallucinations, 
morbid impulses as soon as the least cloudiness of 
albumen appears in his urine. This circumstance sug- 
gests the possibility of the delirium being uraemic in 
these cases. 

The one feature which soonest attracts attention in 
the evolution of cardiac insanity is the intermittent 
march of this psychosis ; it manifests itself paroxys- 
mally, its accessions being habitually followed by 
remissions supervening under the influence of rest and 
treatmen t. 

In making a diagnosis of cardiac insanity, it is nec- 
essary to lay great stress on the fact of a cardiopathy 
anterior to the disorders of intelligence ; then the re- 
mittent character of the delirium, and its coincidence 
with manifest troubles in the functions of the heart 
will be important elements of diagnosis. 

A third character, to which great importance is at- 
tached, is the precordial distress which precedes and 
accompanies the explosion of the delirium. 

In the treatment of this kind of insanity, great reli- 
ance must be placed on the heart tonics, especially on 



digitalis, frequently administered in small doses ; it 
has been found that large doses rather aggravate than 
arrest the delirium. Bull speaks highly of the utility 
of hypodermic injections of sparteine and morphine, 
which have a very rapid action in arousing and sus- 
taining a fatigued and flagging heart. The sedative 
action of the alkaline bromides on the nervous system 
constitutes them a precious auxiliary. Repose and 
isolation are indispensable ; it will often be necessary 
to send the patient to a sanitarium, or even to an 
asylum ; sometimes a sea voyage will give just the rest 
and freedom from care and business that is needed. 



MEDICAL NOTES. 

— The Boston Transcript having said that " we 
have a ridiculous surplus of doctors in the United 
States," the Traveller asks if the Transcript can men- 
tion any profession that has not a surplus of practi- 
tioners? We object to the expression "ridiculous." 
It might be ridiculous if it were not extremely pathetic. 

— The New York State Care of Insane Act requires 
that all doctors who have been granted certificates of 
examiners in lunacy by a judge of a court of record as 
required by law, shall file a copy of such certificate in 
office of the State Commission in Lunacy. 

Commitments of persons signed by physicians who 
have not filed such a certificate have been received in 
the office of the State Commission in Lunacy, and 
have been declared illegal. Commissioner Brown says 
the law will be strictly enforced in this respect. 

— The Path, a journal of theosophy, in its current 
number contains the following calm description of the 
objects and methods of vivisection : " Through a 
creature crucified alive to a plank, cut into with knives, 
torn with saws, burnt with acids or hot irons, pierced 
through and through with nails, scalded inside or out- 
side with boiling water, wetted with spirits and set on 
fire, whose eyes and organs and limbs are dissected 
out bit by bit, whose nerves and sinews are wrung to 
their utmost tension with hooks, whose whole circula- 
tion is deranged and whose frame is writhing through- 
out with agony — Nature permits no trustworthy 
revelation to be made." 

— The New York Star mentions three physicians of 
that city who have forsaken the path of medicine for 
the thornier one of financial speculation and, strange 
to say, all of them with marked success so far as the 
attainment of wealth. One is Dr. J. H. Parker, just 
elected vice-president of the Park National Bank, who 
made the first steps toward his fortune, estimated as 
in the millions, from cotton speculation, having formerly 
been a medical practitioner in Charleston, S. C. The 
second is Jesse Seligman, of Seligman Brothers, who 
was about to hang out his sign as a doctor in San 
Francisco during the gold excitement of 1848-49, but 
drifted into the banking business instead. The third 
is Dr. Norvin Green, president of the Western Union 
Telegraph Company, who came from Kentucky, and at 
one time made a specialty of lung diseases. 



Vol. CXXIII, No. 5.] BOSTON MEDICAL A 



ND SURGICAL JOURNAL. 



117 



— Dr. Audie Sarzeau, in the Pharm. Zeitung 
(Pharm. Journal, p. 792, 1800) directs attention to 
the considerable solvent action of camphor upon iodo- 
form, lie found that it requires ten grammes of 
alcohol for the solution of .125 gramme of iodoform, 
yet the quantity of the latter dissolved is one gramme 
if the alcohol be first saturated with camphor. 

— The New York World, which is nothing if not 
enterprising, has matched its recent performance of 
Nellie Bly with the doctors by a similar trial on the 
druggists. A reporter took two prescriptions around 
to thirty-six drug stores, had them compounded, paid 
for them, took receipts, then went home and wrote a 
three-column article, which was duly published in the 
World. The two prescriptions, as priced by " a prom- 



inent member of the drug jobbing trade," were as 
below : 

Prescription No. I. 
Sulfonal is valued at $1.35 an ounce. 

Sulfonal, grs. xv, cost 4 cents 7a mills 

Bismuth, sub. carb., £ dram, cost . . . 1 cent 5 mills 
CretiB prep., grs. x, cost cent 2£ mills 



Total 5 cents 15 mills 

Equal to 6J cents. 

Prescription No. II. 

Tinct. opii campb., 1 ounce, cost ... 2 cents 5 mills 

Mist, glycyrrh conip., ounces, cost . . 1 cent 7^ mills 

Syr. acacia, J ounce, cost 1 cent 2j mills 



Total 4 cents 15 mills 

Equal to 5£ cents. 



Thus twelve cents was the actual cost of the mate- 
rials in the prescriptions, and the reporter becomes 
excited when, upon comparing receipts from the stores 
where he had the medicines compounded, he finds he 
has paid sums ranging from thirty-five cents to eighty 
cents, and immediately resorts to mathematics to show 
that the druggists have made from 300 to 400 per 
cent, profit. It is quite fair for the druggists to pro- 
test that the reporter has figured at nil the manipula- 
tive skill of the druggist, and what is worth more, the 
responsibility for the handling with accuracy of pow- 
erful remedies. 

— Mr. C. S. Loch, an active officer of the London 
Charity Organization Society has printed in Murray's 
Magazine a very complete and interesting analysis 
of Medical Relief in London. In London there are 
eleven hospitals with medical schools at which over 
44,000 in-patients and over 550,000 out-patients are 
treated annually, and the medical students find in 
them the best means of perfecting their preparation. 
London has eight general hospitals without schools, 
caring for 5,600 in- and over 107,000 out-patients. It 
has 56 special hospitals with over 26,000 in- and 
398,000 out-patients. London has 39 dispensaries 
with over 260,000 patients, and of late, instead of 
giving medical advice and treatment and medicine 
free, successful efforts have been made to discriminate 
in favor of those really entitled to such wholesale 
charity. Then London has 44 dispensaries main- 
tained by the tax-payers, caring for over 114,000 
patients. The hospitals built and supported by taxes 
supply over 11,900 beds. Out of a total of 23,559 
beds in its hospitals, 17,830 were occupied, the differ- 



ence being due to want of funds, not of patients. 
The nominal deficit of the London hospitals is about 
half a million dollars a year — that sum is needed to 
enable them to use all their accommodations. 

— Many strange ideas of hospitals and hospital ap- 
pointments are being aired just now before the Lords 
Committee, as we learn from the London Lancet, and 
many vague and contradictory statements are made as 
to matters of fact which are apt to prejudice the 
public, or to convey an impression that witnesses are 
speaking at random and without that precision which 
is always to be expected in professional men. One 
view of the honorary surgeoncy to a great hospital 
came out rather strongly in the evidence of one wit- 
ness — namely, that it involved great sacrifice on the 
part of the surgeon. The gentleman was of the 
opinion that the honorary surgeoncy to a well-known 
hospital cost him very dear — lost him, in fact, £2,000 
a year. This is one way of putting it ; but, as our 
contemporary points out, a very one-sided way. " A 
surgeon devotes time to hospital work, but the work 
and the appointment give him reputation. He is not 
asked to hold the appointment longer than suits his 
own convenience. He can fix his private work for any 
hours and days which suit his hospital engagements. 
A dozen young rivals will only be too happy to relieve 
him of his hospital appointment, and to them it would 
not mean a loss of £2,000 a year. We do not under- 
value the great services to hospitals rendered by sur- 
geons of secured fame. But they must not ask the 
public to pity them too much. It is not a form of 
martyrdom that can be too much magnified." 

M. PASTEUR AND HYDROPHOBIA. 

An article by Thomas M. Dolan, M.D., in the Con- 
temporary Review for July, contains a strong arraign- 
ment of the success of the Pasteurian treatment against 
hydrophobia. We make room for a few extracts : 

"It is now thirteen years since ... 1 investigated 
carefully a number of cases of alleged cures by a cler- 
gyman residing near Burnley, who had a great reputa- 
tion in Lancashire for the cure of hydrophobia. The 
result of my inquiry showed that the Rev. Dr. Verity, 
the clergyman in question, had had a large number 
(two thousand) of dog-bitten patients. A few of them 
had died from hydrophobia after his treatment; but 
the majority escaped, the reason being that they had 
been bitten by non-rabid dogs, or had been bitten 
through clothing, etc. I inquired into numerous other 
alleged cases of cure of hydrophobia, but always with 
the same result; and I was thus led to formulate this 
proposition, — 'that if any one obtained a reputation 
for the prevention of hydrophobia, and if all the dog- 
bitten sought or took this remedy, the result would be 
statistically favorable.' 

"I found, on carefully comparing the statistics given 
by M. Pasteur with those of the years which preceded 
the introduction of his system, that the supposed rabid 
dog-bitten in France had increased in extraordinary 
proportions ; while, at the same time, the average 



118 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[July 31, 1890. 



mortality from rabies in France had shown but little 
fluctuation. 

" In explanation of the deaths, a general affirmation 
was made that the cases that died came ' too late.' 
But, in looking through the list of patients, I found 
that I he cases which were ' cured ' were, in many cases, 
of just as long duration, and that with regard to them 
no assertion was made that they came ' too late.' 
Take, for instance, the case of Lord Doneraile. If, in 
his case, eleven days was too late for treatment, then 
all cases that came after that period had elapsed must 
be expunged from the list of cures. Or, if Lord Don- 
eraile's death was due to the application of the weak 
or first method, then the cases of the others treated by 
the same formula fall to the ground. 

Dr. Dolan cites the classification which Pasteur 
has adopted with regard to the proofs that the patients 
he has treated were bitten by dogs that were really 
suffering from rabies. The following is the form 
adopted : Class A. Cases in which the dog was proved 
to be rabid by the experimental test ; Class B. Cases 
in which the dog was recognized as rabid by the vet- 
erinary surgeon ; Class C. Cases in which the dog was 
only suspected of being rabid. 

" This classification presupposes that all the patients 
have been exposed to danger. It makes no allowance 
for non-rabid dogs, with the strange result, that, ac- 
cording to these statistics, a veritable epidemic of 
rabies, affecting thousands of dogs, must have existed 
in France during the years which have elapsed since 
M. Pasteur introduced his system. 

" Dr. Dujardin-Beaumetz. Director of the Sanitary 
Service of Paris, has addressed to the prefect of police 
a report on hydrophobia in Paris, furnishing the fol- 
lowing data of comparison : 

" For the four years antecedent to Pasteur the 
deaths were 38, namely, in 1882, 9; in 1883, 4; in 
1884, 3; in 1885, 22. 

" For the four years of treatment the deaths were 
37, namely, in 1886, 3; in 1887, 9; in 1888, 19; in 
1889, 6. 

"On November 2, 1887, M. Pasteur wrote to the 
Academy of Medicine as follows : ' We know that 
sixty persons have died in the Paris hospitals during 
the last five years, a mean of twelve per year.' " After 
careful investigation of the hospital returns for those 
years, Dr. Dolan contradicts this statement, and 
submits a full list of the names of all the patients who 
died in the Paris hospitals during that time, showing 
the following results: in 1881, 11 died; in 1882,3; 
in 1883, 4; in 1884,3; in 1885,5. This gives a 
total of 26, or an average of 5.2 per annum, in place 
of the annual average of 12, as estimated by M. Pas- 
teur, of French patients treated by him, who have 
"died since the introduction of the Pasteurian system. 
The following is a recapitulation : in 1886, 19 
deaths; in 1887, 27 deaths ; in 1888,23 deaths; in 
1889, 21 deaths; giving a total of 80, or a yearly 
average of 20. These cases only represent the deaths 
after inoculation by M. Pasteur. To obtain the an- 
nual mortality of rabies in France, we must add to the 
foregoing the deaths of those persons who have not 
been treated at the institute. According to statistics 
published by M. Pasteur himself in 1886, the deaths 
among the non-inoculated for that year amounted to 
17. If these be added to the 19 who died after treat- 
ment, we have an annual mortality of 36, as against 
an annual mortality, according to Tardieu's returns, 



prior to the introduction of inoculation, of 25 to 30. 
With these statistics before us, we are forced to the 
conclusion that the words of Sir James Paget in his 
recent address at the Mansion House were prompted 
more by generous impulse, and by feelings of respect 
and friendship for Pasteur, than by any strict 
regard to statistical data. As we have seen, Sir 
James Paget fixes the general mortality of those bitten 
at 15 per cent. M. Pasteur, in his article in the New 
Review (December, 1889), accepts this estimate, but 
thinks it is too low for bites on the face and other 
exposed parts. In such cases he thinks that the fig- 
ures should be from 60 to 90 per cent. If we add up 
the number who have beeu bitten on exposed parts, 
and accept these percentages, then M. Pasteur's sav- 
ing of life has been much greater, and his cures for 
France alone amount to some hundreds per annum. 
When we remember the ascertained mortality in 
France, and the rarity of hydrophobia there in past 
years, such percentages as the foregoing reduce the 
system to an absurdity." 

TENOTOMY TO INCREASE THE MOBILITY 
AND POWER OF THE MUSICIAN'S RING- 
FINGER. 

Considerable attention having been lately attracted 
to the above subject we subjoin extracts from a paper 
by Dr. F. W. Langdon, in the Cincinnati Lancet Clinic, 
for July 5, 1890: 

" The limited range of independent extension pos- 
sessed by the fourth digit of the hand is well known, 
and is usually a most formidable stumbling-block to 
the pianist and other performerson keyed and stringed 
instruments, in the production of certain notes, and 
musical effects, as trills for example. 

" The causes of this impairment of mobility, which 
is associated with a corresponding lack of power in the 
digit, are two in number, namely : (1) mechanical, 
due to structural peculiarities of the parts ; and (2) 
physiological, due to insufficiency of muscular develop- 
ment; the latter being dependent on the former. 

"The mechanical obstacles to free extension, as any 
one may satisfy himself by dissection, or even by ex- 
amination of the average living haud, are two oblique 
tendiuous bands, situated about three-quarters of an 
inch above the knuckle line, connected proximally with 
the extensor tendon of the ring-finger and distally with 
the common extensor tendons on either side, namely : 
those to the middle and little fingers. 

" That these subsidiary tendons act as ' guy ropes,' 
and limit the extensor range of the ring-finger espec- 
ially, may be determined by any one for himself, by 
placing the hand on a flat surface and extending, first, 
the ring-finger alone ; then extension of its neighbors 
on either side will demonstrate that all three can be 
brought higher than either one alone. The little fin- 
ger is seen to be less affected than either of the others, 
owing to its possession of a proper extensor, which is 
free, while the middle finger is less limited than the 
ring, by reason of having the 'guy ' tendon on one side 
only. 

"These diagonal tendinous bands are constantly 
present, though varying somewhat in development and 
position in different persons. 

" Not only is extension of the ring-finger diminished, 
but separation of the three inner digits is materially 
lessened by the presence of these apparently insignifi- 



Vol. CXXIII, No. 5.] BOSTON MEDICAL AND SURGICAL JOURNAL. 119 



cant slips, so that the lateral " spread of the digits is 
impaired to such a degree as to become an important 
matter to the musician. Again, in addition to the 
mere limited range of motion, both vertically and lat- 
erally, due to the mechanical effects of these slips, 
there is also to be considered the physiological factor, 
namely, lessened functional activity and consequently 
faulty development of the muscular (ibres acting on the 
extensor tendon of the ring-finger, namely, fibres of 
the common extensor, fourth dorsal interosseous and 
third lumbricalis. This faultof development is a more 
important matter than would appear at first glance, 
since it is mainly by the interossei and lumbricales that 
the first phalanges are flexed and the second and third 
extended, whence the name ' fidicinales.' " 

The performance of the operation in one case is 
thus described. " The field of operation was prepared 
by thorough cleansing. The skin, with a large branch 
of the dorsal venous arch, was now slipped aside with 
the thumb, so as to leave clear of vessels the inter- 
space between the third and fourth metacarpals in the 
neighborhood of the proposed incision. Moderate 
flexion of the patient's hand enabled the operator's 
finger to define the position and direction of the outer 
(radial) connecting slip, which varies slightly in differ- 
ent subjects ; its middle averaging perhaps three- 
quarters of an inch above the knuckle line. With an 
ordinary sharp-pointed tenotomy knife a longitudinal 
incision, one-eighth inch in length, midway between 



the third and fourth metacarpals, and just to the 
distal side of the slip to be divided, is carried through 
the skin and superficial fascia. The exact location of 
the slip having now been determined by means of a 
probe — the deep fascia is incised at the lower edge of 
the slip and the point of the knife carried directly up- 
ward, that is, toward the wrist, beneath the slip, which 
parts with the characteristic creaking sound and feel. 
If not sufficiently tense to divide easily, it may be made 
more resistant by directing the patient to flex the fin- 
gers a little more strongly. The dressing consisted of 
a pledget of absorbent cotton held in place by adhesive 
strapping. 

"A marked increase in range of independent exten- 
sion was at once evident, and within a few days the 
patient remarked a greater precision of touch — there 
being no tendency to the lateral twisting which had 
before annoyed him — and which was at this time ob- 
servable in the other hand. Union of the wound was 
complete when the dressing was removed on the third 
day, and the result of the operation was so satisfactory 
to the patient that he at once submitted the other hand 
to be operated on. The motion attained in both cases 
was so satisfactory that it was deemed unnecessary to 
divide the slip going to the little finger tendon. In 
some extreme cases, however, this also would probably 
require division, in which event it would be well to 
bear in mind its lesser length, and not mistake for it 
the common extensor tendon, going to the fifth digit." 



REPORTED MORTALITY FOR THE WEEK ENDING JULY 19, 1890. 













Percentage of Deaths 


from 






Estimated 


Reported 


Deaths 












Cities. 


Population 


Deaths in 


under Five 


Infectious 


Consump- 


Diphtheria 


Diarrhoeal 






for 1890. 


each. 


Years. 


Typhoid 






Diseases. 


tion. 


and Croup. 


Diseases. 


Fever. 


New York . . . 


1,622,237 


941 


538 


36.85 


10.56 


2.31 


30.14 


.55 




1,100,000 
















Philadelphia .... 


1,061,277 


437 


205 


26.22 


10.58 


2.07 


20.47 


1.61 




852,467 


523 


318 


36.48 


9.12 


4.18 


27.74 


.19 




550,000 


163 


85 


23.79 


5.49 


1.83 


18.91 


2.44 




500,343 


248 


96 


26.40 


9.20 


1.60 


16.80 


3.60 




418,110 


219 


101 


26.32 


12.22 


3.29 


21.62 


.47 




325,000 


123 


48 


28.35 


17.00 


6.48 


4.86 


4.86 


New Orleans .... 


260,000 


















240,000 


















240,000 


















230,000 


122 


61 


28.70 


11.48 


1.64 


14.76 


8.20 




68,513 


38 


19 


34.19 


5.26 




26.30 


2.63 




60,145 


34 


16 


20.58 


5.88 




11.76 


5.88 




42,000 


12 


2 














81,622 


31 


21 


45.22 


6.46 




45.22 






73,370 


56 


36 


39.16 


10.68 




35.60 


3.56 


Cambridge 


67,026 


33 


22 


42.42 


3.03 


3.03 


36.36 




Fall River 


64,092 


48 


32 


49.92 


10.40 




49.92 






55,200 


14 






7.14 










41,520 


11 


4 


27.27 


18.18 




27.27 






41,058 


31 


18 


38.76 






32.30 




New Bedford .... 


38,218 


15 


11 


33.33 


6.66 




33.33 






37,867 
















Somerville 


35,516 


















30,811 


















29,242 


9 


5 


11.11 


11.11 










28,781 


16 


7 


18.75 


12.50 




18.75 






27,124 


17 


11 


52.92 


11.76 




52.92 






25,544 


8 


4 


25.00 


12.50 




25.00 






24,904 


8 


4 




25.00 










22,011 


7 


1 














20,615 


6 


3 


16.66 


16.66 




16.66 






17,998 


4 


1 




25.00 










17,304 


3 


2 


33.33 






33.33 




Attleborough .... 


15,954 


















15,762 


2 







50.00 










14,114 


2 


1 












Newburyport .... 


13,915 


4 


1 




25.00 










13,089 

















120 



BOSTON MEDICAL AND SURGICAL JOURNAL. [July 31, 1890. 



Deaths reported 3,185 ; under five years of age 1,673 : principal 
infectious diseases (small-pox, measles, diphtheria and croup, 
diarrhceal diseases, whooping-cough, erysipelas and fevers) 963, 
consumption 306, acute lung diseases 175, diarrhceal diseases 
785, diphtheria and croup 78, typhoid fever 48, whooping-cough 
43, measles 16, scarlet fever 12, malarial fever 12, cerebro- 
spinal meningitis 6, erysipelas 3. 

From whooping-cough, New York 15, Brooklyn 11, Philadel- 
phia 7, Baltimore 3, St. Louis, Boston, Washington, Charleston, 
Cambridge and Salem 1 each. From measles, New York 11, 
Brooklyn 2, Baltimore, Washington and Lawrence 1 each. From 
scarlet fever, New York 7, Philadelphia and Brooklyn 2 each, 
Baltimore 1. From malarial fever, Baltimore 6, Brooklyn 5, 
Nashville 1. From cerebro-spinal meningitis, Washington 3, 



Brooklyn 2, New York 1. From erysipelas, New York, Brook- 
lyn and Boston 1 each. 

In the twenty-eight greater towns of England and Wales with 
an estimated population of 9,715,559, for the week ending July 
12th, the death-rate was 17.7. Deaths reported 3,305: infants 
under one year 636, diarrhoea 177, measles 163, whooping-cough 
112, scarlet fever 70, diphtheria 36, fever 26. 

The death-rates ranged from 10.4 in Norwich to 25.3 in 
Newcastle-on-Tyne : Birmingham 19.2, Bradford 13.9, Hull 
11 7, Leeds 18.1, Liecester 19.9, Liverpool 22.8, London 17.4, 
Manchester 23.1, Nottingham 12.8, Sheffield 16.9, Sunderland 
19.9. 

In Edinburgh 16.7, Glasgow 23.0, Dublin 21.3. 



The meteorological record for the week ending July 19, in Boston, was as follows, according to observations furnished by 
Sergeant J. W. Smith, of the United States Signal Corps: — 



Week ending 


Barom- 
eter. 


Thermometer. 


Relative 
Humidity. 


Direction of 
Wind. 


Velocity of 
Wind. 


State of 
Weather.* 


Rainfall. 


Saturday, 


a 
a 


a 




s* 








a 

C3 




















a 
rig 


a 


July 19, 1890. 


o 

p-> 


s 


j 
5 


a 

a 

'3 


a 

■4 




53 


« 
S 

>> 


S3 
■S 




S3 
pC 


S3 

■i 




S3 


sj 




S3 


cs n 


+3 OQ* 

a a> 












o 




o 




© 




o 


© 




© 


© 




© 


a u 


a? 




'3 


'5 


3 


i 


© 




o 


'3 


© 




© 


© 




© 


© 




© 


5w 






Q 


A 






CO 




CO 


P 


CO 




CO 


CO 




CO 


CO 




CO 


A w 


< 


Sunday,. ..13 


30.10 


67.0 


75.0 


59.0 


66 




68 


67.0 


s. 




S.W. 


12 




6 


F. 




F. 






Monday, ..14 


30.08 


67.0 


78.0 


56.0 


89 




68 


79.0 


N.W. 




S.W. 


8 




12 


O. 




C. 






Tuesday,.. 15 


29.99 


77.0 


91.0 


64.0 


80 




72 


76.0 


S.W. 




S.W. 


21 




8 


O. 




O. 






Wednes. ..16 


30.02 


82.0 


93.0 


72.0 


56 




37 


46.0 


w. 




S.W. 


10 




7 


O. 




C. 






Thursday, .17 


29.87 


76.0 


84.0 


68.0 


50 




45 


47.0 


w. 




w. 


3 




14 


O. 




F. 






Friday 18 


29.90 


72.0 


76.0 


68.0 


52 




38 


45.0 


N.W. 




N. 


24 




7 


c. 




C. 




0.07 


Saturday, .19 


29.93 


65.0 


74.0 


56.0 


61 




65 


63.0 


S.W. 




N. 


12 




10 


0. 




F. 






Mean for 
Week. 





























* O., cloudy ; C, clear ; F., fair ; G., fog ; H., hazy ; S., smoky ; R., rain ; T., threatening ; N., snow, t Indicates trace of rainfall. 



OFFICIAL LIST OF CHANGES IN THE MEDICAL CORPS 
OF THE U. S. NAVY FOR THE WEEK ENDING JULY 
26, 1890. 

Stone, L. H., assistant surgeon, ordered to the U. S. Receiv- 
ing-Ship "New Hampshire." 

Uric, J. F., assistant surgeon, detached from the U. S. Re- 
ceiving-Ship "New Hampshire," and ordered to U. S. Receiv- 
ing-Ship " Wabash." 

Norton, Oliver D., passed assistant surgeon, granted leave 
of absence for month of August. 

Babin, H. J., surgeon, granted one month's leave of absence 
from July 23d. 



OBITUARY. JACOB ROBERTS, M.D. 

Dr. Jacob Roberts, who died at his residence, in Philadelphia, 
July 20th, of cerebral haemorrhage, was born in that city on 
March 21, 1836. He graduated at the University of Pennsyl- 
vania in 1862, and soon afterwards entered the regular army as 
a medical cadet, and was afterwards commissioned by Governor 
Andrew, of Massachusetts, as an assistant surgeon in the Twen- 
ty-third Massachusetts Infantry. He was with his regiment on 
three battlefields, but his duties for the most part were in the 
hospitals. After a service extending over two years he resigned, 
and began the practice of his profession in Philadelphia, in 
which he met with great success. For many years he was asso- 
ciated with Professor Goodell, of the University of Pennsylvania, 
in conducting a lying-in charity. 



BOOKS AND PAMPHLETS RECEIVED. 

Session of 1890-91. Annual Announcement of the New York 
Polyclinic and Hospital, a Clinical School for Graduates in 
Medicine and Surgery. 

A Treatise on Rheumatism and Rheumatoid Arthritis. By 
Archibald E. Gar rod, M.A.. M.D., Oxon., M.R.C.P., etc. With 
charts and illustrations. Philadelphia: P. Blakistou, Son & 
Co. 1890. 



Fact and Theory Papers. Protoplasm and Life. Two Bio- 
logical Essays. By Charles F. Cox, M.A. New York : N. D. C. 
Hodges. 1890. 

The Nature of the Giant-Cells of Tubercle and the Elements 
Associated Therewith, as Seen in Comparative Pathology. By 
Walter K. Sibley, M.B., B.C., B.A., Cantab. Reprint. 

Railway Hygiene, and the Necessity of Sanitary Inspection 
and Supervision of Railway Coaches, Buildings and Grounds. 
An Address to the Association of Railway Surgeons at Kansas 
City, Mo. By G. P. Conn, M.D., Concord, N. H. Reprint. 1890. 

Familiar Forms of Nervous Disease. By M. Allen Starr, 
M.D., Ph.D., Professor of Diseases of the Mind and Nervous 
System, College of Physicians and Surgeons, New York. With 
illustrations, diagrams and charts. New York: Wm. Wood & 
Co. 1890. 

Diseases of the Rectum and Anus, Their Pathology, Diagnosis 
and Treatment. By Chas. B. Kelsey, A.B., M.D., New York, 
Professor of Diseases of the Rectum, at the New York Post- 
Graduate Medical School, etc. Third edition, rewritten and 
enlarged, with two chromolithographs and 168 illustrations. 
New York : Wm. Wood & Co. 1890. 

Extra Uterine Pregnancy. The History of, by Dr. G. W. Mil- 
tenberger; Laparotomy for, with Report of a Successful Case, 
by Dr. T. A. Ashby; Review and Discussion, by Dr. H. A. 
Kelly ; General Discussion. Papers read before the Obstetrical 
and Gynecological Society, of Baltimore City, January 14 and 
February 11, 1890. Published by order of the Society. 

Ueber Feuerbestattung. Vortrag gehalten am Abende des 
13 Februars, 1890, in Verbindung mit Experimenten und unter 
Vorweisung von kolorierten Bildern in Naturwissenschaftlichen 
Vereine zu Miilhausen im Elsasse. Nebst Anhang und mit 
fiinf Abbildungen im Texte, von Prof. Dr. Friedrich Goppels- 
rcsder. Druck und Verlag von Wenz & Peters, Miilhausen i. 
Els. 1890. 

An Investigation into the Etiology of Phthisis. By Heneage 
Gibbes, M.D., Professor of Pathology in the University of Mich- 
igan ; and E. L. Shurly, M D., Professor of Laryngology and 
Clinical Medicine in the Detroit College of Mediciue. Part II. 
On the Clinical History of Phthisis Pulmonalis. By E. L. 
Shurly, M.D. Part IV. On the Etiology and Local Treatment 
of Phthisis Pulmonalis. By E. L. Shurly, M.D. Reprints. 1890. 



Vol. CXXTII, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



121 



Original 3Urtide0. 

SOME POINTS IN THE TREATMENT OF 
GONORRHOEA. 1 

BY OARDNKK W. ALLKN, M.D., 

Surgeon in the Oeni l»- Urinary Department, lloston Dispensary. 
THE ANTEKIOU UKKTHRA. 

The fact that gonorrhoea, even under favorable 
conditions, has a strong tendency to become chronic, 
and the acknowledged difficulties encountered in treat- 
ing the disease in its later stages, give it an importance 
to the physician perhaps out of proportion to the seem- 
ing insignificance of the symptoms. A slight urethral 
moisture, without subjective symptoms, will sometimes 
keep the patient in a state of worry and depression, 
and the physician at his wits' end, trying one remedy 
after another, for months ; yet, if Noeggerath's teach- 
ings are to be followed, and they are apparently gain- 
ing more and more advocates among the gynecologists, 
the importance of absolute extinction of the disease in 
every case can scarcely be exaggerated. 

Various forms of treatment are, from time to time, 
recommended, promising quick and permanent cure 
for gleet; but most of them are disappointing. The 
reports of sucli brilliant results are probably based on 
too small a number of cases. Chronic urethritis is 
an uncertain as well as an obstinate affection. It 
occasionally happens that a slight chronic discharge 
will stop spontaneously, almost abruptly, and some- 
times a sound passed two or three times, or a simple 
injection for a few days will check a discharge, and re- 
lieve symptoms that have been going on a long time ; 
but such cases are the exception, not the rule, and 
should not be cited as showing the remarkable proper- 
ties of a particular course of treatment. The slight 
exacerbations to which some men are subject who 
have previously had gonorrhoea, not due to fresh in- 
fection, but following excesses, often yield promptly 
to simple astringent injections ; a very few injections 
of a corrosive-sublimate solution will almost surely 
check such outbreaks. Corrosive sublimate (1 to 10,- 
000 or 20,000) also makes a very good, and I think 
the best, injection for chronic discharge. 

Irrigation of the urethra, with a quart or more of 
warm solution, through a bluut nozzle held at the 
meatus, or, still better, through a catheter passed to 
the bulb, often gives satisfactory results in chronic ure- 
thritis ; potassium permanganate (1 to 2,000), corrosive 
sublimate (1 to 20,000), or creolin (1 to 500) may be 
used in this way. The latter is quite irritating, and 
should not be used where there is any active inflamma- 
tion. These irrigations may be repeated two or three 
times a week, an injection being used iu the intervals, 
or the patient may irrigate himself every day. A 
sound passed occasionally may be found a valuable 
aid. 

I am convinced, however, that by far the most ra- 
tional method of treating chronic gonorrhoea is by 
means of local applications to the diseased mucous 
membrane through the endoscope. The advantage of 
ocular demonstration of the diseased surface, and of 
being able to observe directly the effect of treatment, 
is obvious. In October, 1887, I reported before the 
Suffolk District Society some cases of urethral endo- 
scopy treated at the Boston Dispensary, and showed 

1 Read at the meeting of the Surgical Section of the Suffolk Dis- 
trict Medical Society, April 2, 1890. 




some of the endoscopes designed by Dr. Hermann G. 
Klotz, of New York, and described by him in a very 
interesting article in the New York Medical Journal, 
November 27, 1886. (See 
Fig. 1.) These endoscopes 
are straight, open tubes, of 
different sizes and lengths, 
made of coin silver, which 
allows of their being very 
thin and light, and is not af- 
fected by the solutions used 
in treatment. Any strong, 
steady light, reflected into 
the tube from a head-mir- 
ror, will sufficiently illumi- 
nate the urethra to admit of 
a close study of its patho- 
logical appearances. Hav- 
ing been passed down to the 
bulb, and the conductor 
removed, the endoscope is 
slowly withdrawn, giving op- 
portunity for careful inspec- 
tion of the mucous mem- 
brane and for treatment. 
( ) Lili The applications are made 

by means of a cotton tam- 
Klote'B Endoscope. pQn Qn th(J end Qf ft ^ 

and as large an endoscope as will pass the meatus 
should be used. 

A more or less deep or livid congestion, with cede- 
matous swelling of the mucous membrane, dilated cap- 
illaries here and there, and a granular appearance in 
places, is the commonest condition. It may be nearly 
evenly diffused over the whole surface of the anterior 
urethra, but is generally more circumscribed, notably 
in the bulbous portion, but especially about the peno- 
scrotal angle, where it is most marked, as a rule, ac- 
cording to my experience. The latter situation, or 
just anterior to it, is a common seat of stricture of 
large calibre, recognized by a rigid state of the mucous 
membrane, which is often associated with inflammation 
of the mucous glands of the urethra. When this con- 
dition is present, the inflammation is apt to linger here 
after it has subsided in the bulbous portion and else- 
where, and, when the general congestion has been par- 
tially reduced, the mouths of the glands may be seen 
as small points, each surrounded by a dark red or red- 
dish-brown areola. In these cases of stricture recov- 
ery will almost surely be retarded, and it makes but 
little difference of how large calibre the stricture is. 
In one case a 38 (French) sound passed easily ; yet 
a stricture was distinctly defined by a bougie a boule, 
and it proved a very troublesome complication. 

Other abnormities described by authors on endo- 
scopy include variations in color and smoothness of 
the mucous membrane, thickening of the epithelium 
iu stripes, erosions and ulcerations, polypi, papilloma- 
tous growths, etc. The latter, constituting the rare 
affection described by Oberlander, of Dresden, as 
papillomatous urethritis, I have had an opportunity 
of seeing, through the kindness of Dr. F. M. Briggs, 
whose very interesting case is reported in the Boston 
Medical and Surgical Journal, October 24, 1889. 

In endoscopic examination the light reflexes, mi- 
nutely described by Griinfeld, sometimes a hindrance 
and sometimes an aid to the clearness of the view, 
should be carefully noted and taken into account, also 



122 



BOSTON MEDICAL AND SURGICAL JOURNAL. [August 7, 1890. 



the effect on the color of the mucous membrane — 
paleness — produced by pressure of the end of the 
tube and of the cotton tampon. 

In treatment, I have used nitrate of silver almost 
exclusively, and generally begin with a one per cent, 
solution and increase the strength gradually to ten per 
cent., if well borne. The cases which tolerate the 
stronger solutions seem to do better, as a rule. The 
applications are, of course, limited to the parts actually 
diseased, whereby the healthy parts are spared un- 
necessary irritation, and the stronger solutions, the 
quantity being small, may be safely used. A slight 
discharge for twenty-four or thirty-six hours, with 
moderate pain on micturition, is the only reaction to 
be expected. It would evidently be impossible to use 
an injection of anything like the same strength with- 
out setting up acute inflammation. The applications 
should be made every four to seven days, and, if 
thought advisable to use injections in the intervals, 
ordinary astringents may be prescribed, or a solution 
of corrosive sublimate (1 to 10,000 or 20,000) ; and 
sounds may be passed occasionally with advantage. 
A narrow meatus should be cut, strictures cut or di- 
lated, and other complications treated according to 
indications. 

The cases of stricture complicated with glandular 
disease are slow in their progress toward recovery, 
but generally do well in the end. The silver solution 
seems to work gradually into the mouths of the glands, 
and may help to promote absorption of the stricture 
tissue ; this, I think, I have observed in one case. 
Klotz uses sulphate of copper where these glands are 
involved. These strictures are so resilient that very 
little can be accomplished by dilatation, and many 
patients object to being cut. Oberliiuder 2 treats them 
by forcible dilatation by means of his dilator, in which 
spreading blades may be opened to any extent. The 
dilatation is carried a little farther at each sitting, 
until the stricture is ruptured and the diseased glands 
split open, when applications of nitrate of silver (two 
to five per cent.) are sufficient to complete the cure. 

Other diseased conditions are to be treated accord- 
ing to indications, and I will not go into details here. 
Ulcerations generally require strong applications or 
cauterization, polypi should be removed with the snare, 
and papillomata by means of the curette. 

Fortunately, however, in most cases we have to do 
with a simple inflammation of the urethra. As a rule, 
they do well, and it is very satisfactory to see the 
mucous membrane gradually fading and assuming a 
normal appearance, and to hear the patient's expres- 
sions of gratification as he feels his disagreeable sensa- 
tions passing away. The duration of treatment, of 
course, varies in different cases. In an ordinary un- 
complicated case, a dozen sittings, covering a period 
of about two months, would probably suffice. Here 
is an average case : 

Case I. E. C, age twenty-one, began treatment 
with the endoscope August 13, 1888, after some pre- 
liminary treatment to diminish the discharge. First 
gonorrhoea a year and a half ago; duration six months. 
Second attack six months ago; discharge continues to 
date. Mucous membrane highly congested in the 
bulbous portion, gradually- shading off anteriorly ; 

* See " A Resume of the Views of Dr. Oberliinder, etc.," by J. A. 
Fordyce, M.I)., In Journal of Cutaneous and Genito-Urinary Dis- 
eases, January, 18*9. There Is also a detailed description of the 
treatment in Volkrnann's " Sammlung Klinischer Vortriige," No. 
375, May 31, 1886, p. 14. 



quite oedematous in the middle portion. Solution of 
nitrate of silver, one per cent., applied. The history 
is simply that of gradual improvement in the appear- 
ance of the mucous membrane, the intense congestion 
fading out and leaving a nearly normal condition with 
simultaneous amelioration of subjective symptoms. 
A two per cent, nitrate of silver solution was applied 
August 17th; three per cent. August 20th, 24th and 
27th ; four per cent. August 30th ; five per cent. 
September 5th; seven per cent. September 8th; and 
ten per cent. September 11th. The patient here sud- 
denly broke off the treatment against my advice, and 
immediately plunged into excesses which he kept up 
almost uninterruptedly, without the least apparent dis- 
advantage, until the following summer, when he had 
a slight exacerbation, which was easily controlled by 
a few injections of corrosive sublimate. 

THE POSTERIOR URETHRA. 

In passing the endoscope beyond the bulb into the 
deep urethra, great care should be observed to avoid 
injury to the delicate and inflamed mucous membrane 
held down against the end of the instrument, as it is, 
by powerful muscular contraction. Griinfeld recom- 
mends a hard rubber tube for this purpose, the edges 
not being as sharp as those of the metallic instrument ; 
he passes it without a conductor, and is thereby en- 
abled to keep the visceral end, under control of the 
eye, constantly in the axis of the urethra. A smaller 
endoscope should be used than in the anterior urethra, 
not larger than 24 F., according to Klotz. 

The color of the mucous membrane is normallj of 
a deeper red than in the spongy portion. With some 
practice and carefully guarding against expulsion of 
the tube by sudden and convulsive contractions of the 
external sphincter, the caput gallinagiuis may be rec- 
ognized as a bright-red rounded prominence in the 
lower part of the field with a crescent of dark-red 
mucous membrane above it. Bleeding is very easily 
excited in the deep urethra, which obscures the view 
and renders treatment less effective. 

Pathological distinctions are less easily recognized 
through the endoscope than in the anterior portion. 
Griinfeld describes hyperemia, catarrhal swelling and 
hypertrophy of the caput gallinagiuis, but Klotz thinks 
that differences in size of this organ may be due to 
individual peculiarity. Applications are made as in 
the anterior portion, but the solutions used should gen- 
erally be milder. 

Three years ago, Dr. E. L. Keyes, of New York, 
read before the American Association of Genito- 
Urinary Surgeons a valuable paper on " Deep Injec- 
tions of Nitrate of Silver." * He uses for the purpose 
a modification of Ultzmann's deep urethral syringe, 
the essential feature of which is a long, curved nozzle 
of pure silver with a pinhole opening in the end. (See 
Fig. 2.) He begins with a very weak solution, one 
grain to the ounce, and gradually increases the 
strength, rarely going above two per cent. Keyes 
thinks that most of the disagreeable results of this 
treatment, which have limited its popularity in the 
past, are due to passing the instrument too deeply into 
the prostatic urethra, and considers it important that 
the point of the syringe should just enter the mem- 
branous portion. Two or three minims of the solu- 
tion deposited here will diffuse themselves backward 
• New York Medical Record, May 28, 1887. 



Vol. CXXIII, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



123 



B 



over the mucous membrane aurl penetrate into the 
prostatic urethra. He prefers to inject before micturi- 
tion, because otherwise the nitrate of silver is decom- 
posed by the urine with which the 
urethral walls are bathed, but he al- 
lows the patient to urinate soon after, 
and then has him hold his water as 
long as possible and avoid straining. 
When there is much pus, however, 
he has the patient urinate first, and 
then injects a larger quantity (five 
minims), which will not be decom- 
posed. 

Keyes reports cases, successfully 
treated by this method, of acute and 
sub-acute gonorrhoea] cystitis ; acute 
and chronic deep urethral inflamma- 
tion ; double relapsing epididymitis 
due to the latter ; irritability of the 
bladder ; the same due to enlarged 
prostate ; oxaluria, prostatic neurosis 
and sexual weakness. He also rec- 
ommends it in prostatorrhoea, sper- 
matorrhoea, nocturnal emissions, and 
nervous impotence. 

The results obtained by these deep 
injections are certainly, in many cases, 
among the most satisfactory in the 
treatment of urethral disease. Al- 
though not uniformly successful, they 
are generally so, aud, if the patient 
is to be benefited, he will show signs 
of improvement after the first or 
second injection, as a rule. The 
treatment may be repeated every 
three or four days, and in inflamma- 
tory trouble a very few injections 
are generally sufficient. Impotence requires more 
and stronger injections. 

I usually inject after micturition, and use five or 
six minims of the solution, beginning with one-half 
per cent, and increasing the strength gradually to two 
per cent. With a finger in the rectum, in the sulcus 
between the bulb and the prostate, the tip of the syr- 
inge may be felt as it enters the membranous portion, 
and a too deep insertion of the instrument thereby 
guarded against. It seems to me that this method of 
treatment is best adapted for gonorrhceal cystitis and 
other inflammatory affections of the prostatic urethra. 
A few cases will best illustrate the effects of the treat- 
ment. 

Case II. M. B., aged thirty-three, came to the dis- 
pensary August 6, 1887, with acute gonorrhoea, which 
was treated in the usual way, with diuretics and injec- 
tions, until August 30th, when the discharge was dimin- 
ished ; but he reported that he had been seized a day 
or two before with frequent, painful and bloody mic- 
turition. In great distress at time of visit ; it was 
impossible to hold water more than an hour, and a 
small quantity of purulent, bloody uriue would then 
be passed with great pain, and followed by severe vesi- 
cal tenesmus. A deep injection of nitrate of silver, 
one-half per cent., was given. 

September 1st. Urinary symptoms entirely relieved, 
but he has pain in testicle ; September 3d, testicle 
greatly swollen. 

The patient had an acute epididymitis, which ran 
the usual course. He considered it a trifle, however, 




Fig. 2. Ultzmanu's 
Deep Urethral 
Syringe. 



compared with the suffering he had endured with cys- 
titis. There was no return of urinary symptoms ; the 
relief was prompt, complete and permanent. Whether 
the epididymitis in this case was the result of the in- 
jection, the nozzle of the syringe; having been inadver- 
tantly pushed too far in, or whether it occurred in the 
ordinary course of the disease, it is impossible to 
say. 

Case III. J. H., aged twenty-four, on October 22, 

1887, had gonorrhoea of six weeks' duration, with a 
copious, thin discharge, and for a week had been suf- 
fering with frequent micturition with blood at the end 
of the act, and followed by severe tenesmus. Deep 
injection of nitrate of silver, one per cent. 

October 25th. Great relief for thirty-six hours, 
then return of symptoms. Injection repeated with a 
two per cent, solution. 

October 27th. Much better. Injection repeated. 

October 29th. Continued improvement. Micturi- 
tion scarcely more frequent than normal. No tenes- 
mus. 

Case IV. B. A., aged twenty-seven, August 21, 

1888. First gonorrhoea four years ago ; duration, a 
year and a half. Present attack of three months' 
duration ; copious, purulent discharge. Very frequent 
and urgent micturition, with vesical tenesmus by day ; 
no trouble at night. First half of urine passed is 
cloudy, second half slightly turbid. Deep injection of 
nitrate of silver, one per cent. 

August 28th. Marked improvement. Micturition 
much less frequent. Injection repeated. 

September 1st. Micturition normal. Discharge 
has stopped. 

September 11th. Discharge has reappeared. No 
return of urinary symptoms. 

In the treatment of various affections of the deep 
urethra I have obtained good results from irrigating 
the neck of the bladder with a solution of permangan- 
ate of potash. This is a perfectly safe operation, and 
subject to none of the risks associated with the deep 
injections of nitrate of silver. Ultzmann advises com- 
plete emptying of the bladder after irrigation ; and in 
cases of acute inflammation, or when other solutions 
are used, it is probably a wise precaution ; but I do 
not believe that any barm can come from leaving be- 
hind a small quantity of a mild permanganate solution. 
Moderate tenesmus, lasting a short time, is the only 
disagreeable symptom I have observed with mild solu- 
tions, and this is the exception. It has been my prac- 
tice, at the suggestion of Dr. H. W. Cushing, to leave 
part of the solution in the bladder, and I have come 
to regard this as an important factor in the success of 
the operation. The fluid settles down into the neck 
of the bladder, as the patient walks about, and has an 
opportunity to exert its stimulating influence on the 
mucous membrane for a considerable time before it is 
decomposed by the freshly secreted urine. Potassium 
permanganate is rapidly decomposed in the presence 
of organic matter, and herein lies the safety of leaving 
this substance in the bladder, for the astringent and 
stimulating effect, which might become irritating if 
prolonged, is checked as soon as enough uriue is 
secreted to decompose the solution. 

The treatment is conveniently carried out by means 
of Ultzmann's large irrigating syringe and catheter. 
(See Fig. 3.) The syringe holds about five ounces of 
fluid ; the catheter is a short metallic instrument, in- 



124 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [August 7, 1890. 



tended to reach only as far as the back part of the mem- 
branous portion. A fountain syringe or siphon with an 
ordinary gum-elastic or soft rubber catheter may be used, 
but means should be provided for accurately measuring 
the amount injected. Thecath- 
eter, having been filled with 
fluid and the air expelled, is 
passed just beyond the ex- 
ternal sphincter, and four to 
six ounces of the solution, or 
as much as the bladder will 
comfortably hold, are slowly 
injected and allowed to run out 
again. This is repeated until 
the solution comes away with 
as bright red a tinge as it went 
in ; then two or three ounces 
are injected into the bladder 
and left there, the catheter be- 
ing removed. The patient is 
then aliowt.l to go, being told 
to hold his water as long as 
he can without positive dis- 
comfort. I usually begin with 
a 1 to 4,000 or 5,000 solution, 
and gradually increase the 
strength. Solutions stronger 
than 1 to 2,000 are not as a 
rule well borne, and those 
weaker than the first-mentioned 
are so rapidly decomposed as to 
accomplish little. Solutions of 
a strength of 1 to 3,000 and 
of 1 to 2,000 are the most 
useful. 

After employing this method ^ig. 3. Ultzmann's Syringe- 
iii two or three cases of pros- 

tatorrhoea with success, it was tried in several cases 
of cystitis and in one case of spermatorrhoea. 

Like every other treatment it sometimes fails, but 
improvement may be expected and entire relief of 
symptoms has followed in many cases. If good is to 
result it is soon apparent and a few injections only are 
necessary, as a rule, to bring about the desired effect. 
The following are a few illustrative cases. 

Case V. A. C, age forty-six, in very poor general 
health, came to the dispensary September 18, 1888, 
with gonorrhoea of two weeks' duration ; thin, purulent 
discharge, chordee, and frequent, urgent, painful mic- 
turition with vesical tenesmus. He was treated with 
diuretics and tonics, with only temporary relief of the 
urinary symptoms, until October 2d, when the bladder 
was irrigated with a solution of potassium permanganate 
1 to 4,000, two ounces being left in. 

October 6th. Relief for a few hours after irrigation, 
but vesical symptoms have now returned. Irrigation 
repeated with a 1 to 3,000 solution. 

October 9th. Improvement. Irrigation with a 
1 to 2,000 solution. 

October 13th. Urinary symptoms entirely relieved. 

October 20th. Micturition normal. 

Case VI. A. R., age seventy, with no venereal 
history, complained, September 27, 1888, of frequent 
micturition with severe tenesmus and blood at the end 
of each act. Urine nearly clear. Small amount of 
residual urine. Prostate moderately enlarged. He 
was treated with diuretics until October 9th, when 
there was no improvement and he was irrigated witli a 




permanganate solution, 1 to 3,000, two ounces being 
left in the bladder. 

October 13th. Great improvement. Irrigation with 
a 1 to 2,000 solution. The patient did not return, but 
was seen a year later and said that he made a rapid 
and complete recovery after the last visit. The cause 
of the vesical symptoms in this case is obscure. 

Case VII. L. E., age twenty-two years, no vene- 
real history. 

October 18, 1888. For six weeks has been troubled 
with frequent and painful micturition with vesical 
tenesmus ; occasionally passes a small amount of blood. 
Urine turbid ; when passed in two glasses the last half 
is slightly tinged with blood and contains whitish clumps 
which, under the microscope, prove to be only fibrin. 
A few days later the urine contained a heavy sediment 
of pus, most of which was passed toward the end of 
micturition, and a little blood ; albumen one-quarter 
per cent. Prostate slightly enlarged and moderately 
sensitive. Was treated with diuretics with some im- 
provement in subjective symptoms and in character of 
urine, but none as to frequeucy and precipitancy of mic- 
turition, until October 27th, when the bladder was 
irrigated with permanganate solution 1 to 3,000 and 
some fibrinous shreds washed out. Two ounces of the 
solution were left in the bladder. 

October 30th. Marked improvement. Can hold 
water longer. Urine clearer. Irrigation repeated 
with the same strength of solution. He improved 
rapidly after this without further local treatment. He 
was seen a year later and said that his recovery was 
complete and permanent. 

Case VIII. F. G., age twenty-one, tall, well built 
and apparently in perfect health, was first seen Febru- 
ary 29, 1888, and gave the following history. First 
gonorrhoea a year ago ; second, three months ago, dura- 
tion six weeks. Ever since this last attack he has had 
a discharge after micturition and defsecation of a 
whitish, ropy substance. He says that sexual desire 
and power are diminished, but does not feel in the least 
nervous or anxious about his condition. General 
health perfect. 

The patient urinated in my presence and immediately 
afterward passed, with very slight effort, about a tea- 
spoonful of the substance described above which, under 
the microscope, proved to be pure semen. He was 
given pills of iron, ergotiu and strychnia and was not 
seen again until September 12th. 

He then reported that he had taken the pills only 
three weeks and the discharge of semen hadcoutiuued 
uninterruptedly, although he could sometimes prevent 
it by avoiding straining after evacuating the bladder 
or rectum. His general health continued good and he 
had regained sexual power and desire. He again pro- 
duced some semen for examination, although not quite 
as much as before, and it showed the same character- 
istics under the microscope. He was directed to resume 
the pills and the neck of the bladder was irrigated with 
a solution of potassium permanganate 1 to 5,000, two 
ounces being left in. The irrigation was repeated as 
follows, with a gradual diminution in the amount and 
frequency of the discharge : September 1 7th, 1 to 3,000 ; 
September 21st, 1 to 2,000; September 24th, 1 to 
1,500; September 28th, 1 to 1,000. 

October 3d. The last injection was followed by 
severe pain and urgent desire to urinate which was 
resisted for an hour, and then micturition was very 
painful, especially at the end, and accompanied with 



Vol. CXXIII, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



125 



the discharge of a thick reddish substance in clumps 
(permanganate). Very little pain after this. No 
seminal discharge. Local treatment suspended. Pills 
continued. 

This patient has been recently seen and reports that 
there has never been the least return of the seminal 
discharge and he has remained well in all other 
respects. 

GONORRHOEA IN WOMEN. 

Gonorrhoea in women has been a good deal written 
about in recent years and there is great difference of 
opinion as to pathology, especially in regard to the 
relative frequency with which different parts are in- 
vaded. Some authorities think that urethritis is pres- 
ent in every case of gonorrhoea, others consider it as an 
occasional complication only. Bartholin's glands are 
commonly, or rarely, involved, according to the views 
of one writer or another. Some maintain that the 
disease rarely extends beyond the cervix, while others, 
Sinclair for instance, of Manchester, Eng., following 
Noegerath, regard implication of the uterus and its 
appendages as the great danger and believe that it will 
almost surely follow if the progress of the disease be 
not promptly checked. 

As for the vagina it probably always has been and 
still is commonly looked upon as a favorite seat of 
gonorrhoea. Yet Sigmund 4 and Steinschneider 6 of 
Neisser's clinic in Braslau, declare that gonococci do 
not settle upon the mucous membrane of the vulva or 
vagina ; and Sinclair says " it is still a question whether 
there is any such thing as gonorrhceal vaginitis. The 
vagina seems to be the last portion of the genital 
tract, from the uterus downwards, to become affected, 
and the first to get well under any suitable cleansing 
process." 6 He thinks, however, that the vagina in 
children and young girls may provide a more favorable 
breeding ground for the micro-organisms. Bumm's 7 
researches furnish strong evidence of the non-existence 
of vaginal gonorrhoea. He cut out bits of suspected 
mucous membrane and examined them microscopically 
with negative result, and also kept gonorrhceal pus in 
direct contact with the vaginal wall twelve hours with- 
out setting up vaginitis. The discovery of gonococci 
in the secretion about the vulva or in the vagina, of 
course, does not prove that the vulvar or vaginal 
mucous membrane is affected, for they may have come 
from the urethra or cervix. 

In most that has been written on treatment, a good 
deal of space is taken up in detailed descriptions of 
elaborate and more or less severe methods of treating 
the vagina — scraping, scrubbing, cauterizing and 
packing. It seems to me that we should satisfy our- 
selves that gonorrhceal vaginitis really exists before 
resorting to measures, as routine treatment, so heroic 
and so difficult to thoroughly carry out. I believe 
that frequent douching with fairly strong antiseptic 
solutions will be found efficient, as far as the vagina 
is concerned, in a large majority of case3. 

The urethra should be carefully attended to, for 
here the disease is apt to linger. Copaiba and other 
internal remedies used in the male may be employed. 
Skene 8 advises injections of nitrate of silver and sul- 

* Annual of the Universal Medical Sciences, 1888, vol. ii, p. 411. 
e Berliner klinische Wochenschrift, April 25, 1887. 

6 On Gonorrhceal Infection in Women, London, 1888, p. 82. 
' Ueber gouorrhoische Mischinfection beim Weibe. Wiesbaden, 
1887. 

• Diseases of Women, p. 821. 



phate of zinc, with suppositories of iodoform or bis- 
muth. Finger, 9 of Vienna, applies, through an endo- 
scope, tincture of iodine or solution of nitrate of silver, 
two to five per cent. Aubert, 10 of Lyons, gives injec- 
tions of nitrate of silver, or passes the solid stick 
rapidly into the urethra. Erand, 11 of Lyons, curettes 
the urethra, and then applies nitrate of silver. Cul- 
lingworth 12 of St. Thomas' Hospital, London, passes 
into the urethra a sound wound with cotton aixl dipped 
in strong carbolic acid. 

The three surgeons last mentioned treat the cervix 
as they do the urethra, that is, with solid nitrate of 
silver, curette, and strong carbolic acid respectively, 
carrying the applications up to the fundus, if necessary. 
Sinclair injects pure tincture of iodine into the uterus. 

Within the last year improved facilities have been 
provided for the treatment of women in the Genito- 
urinary Department of the Boston Dispensary, and 
more attention has been paid to patients of this class 
than before. The treatment has been more or less 
experimental, but many of the cases have shown 
marked improvement. It has been found difficult, 
however, to induce the patients to come regularly and 
to persevere in treatment after they have improved so 
far as to be free from actual discomfort. The scien- 
tific value of the records, therefore, is not as great as 
could be wished. By way of giving an outline of the 
treatment I have followed, and in the hope of exciting 
criticism and discussion, I report the following case : 

Case IX. Julia B., age twenty-eight, on Septem- 
ber 12, 1889, had a discharge of two months' duratiou. 
She had had more or less leucorrhcea for ten years. 
Physical examination showed the following condition : 
Considerable purulent, urethral discharge ; also a 
vaginal discharge and a copious, glairy, muco-purulent 
discharge from the cervix uteri, with erosion of the 
os. Microscopic examination, by Dr. E. M. Greene, 
showed numerous gonococci in the urethral and cer- 
vical discharge, but none in the vagina. 

The following method of treatment was adopted : 
The vagina was first thoroughly irrigated with a solu- 
tion of corrosive sublimate 1 to 5,000, and the vulva 
carefully cleaned with the same solution. Then, a 
speculum having been passed, the ropy discharge 
clinging to the os was wiped away, and the cervix 
cleaned out as thoroughly as possible. An application 
of carbolic acid (95 per cent.) was then made to the 
cervical canal as far as the internal os, by means of a 
sound wound with cotton, and also to the erosions 
about the external os. The speculum was then slowly 
withdrawn, and any secretion seen on the vaginal walls 
was wiped off with a swab wet with the sublimate solu- 
tion. An ordinary, small-sized, soft rubber catheter 
was next passed into the urethra, and this caual was 
irrigated with the 1 to 5,000 corrosive sublimate solu- 
tion. A suppository, or short bougie, of iodoform was 
then inserted into the urethra and held there until it 
melted. At home the patient used as a douche, twice 
daily, a solution of zinc sulphate and alum, two grains 
of each to the ounce. This was changed later to a 
four per cent, solution of boric acid. 

The local treatment was repeated three times a week, 
and at the seventh visit there was still a slight urethral 

9 Die Blenuorrhoe der Sexual-Organe. Leipzig und Wieu., 1888, 
p. 2-17. 

lu Journal of Cutaneous and Geuito-Urinary Diseases, March, 1889. 

11 Journal of Cutaneous and Genilu-Crinary Diseases, November, 
1889. 

12 Braithwaite's Retrospect, January, 1890, p. 196. 



126 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. 



[August 7, 1890. 



and cervical discharge, but the gonococci had disap- 
peared. The treatment was then interrupted by 
menstruation, and at the next visit was suspended, 
the urethral discharge having stopped and the pus 
having disappeared from the cervical discharge. The 
erosions about the os were entirely healed. 

The patient was seen again January 2, 1890, and 
was found to have a slight urethral discharge contain- 
ing gonococci. There was also some vaginal discharge 
or leucorrhoea, and a moderate amount of colorless, 
transparent, ropy, cervical discharge. The os looked 
perfectly normal. There were no gonococci in the 
vagina or cervix. 

Corrosive sublimate irrigation of the vagina and 
urethra was resumed. The gonococci disappeared 
from the urethra in a short time, but the irrigations 
were kept up, at irregular intervals, for several weeks. 
When occasionally a slight, thin secretion could be, 
with difficulty, pressed from the urethra, it was exam- 
ined under the microscope, but always with negative 
result. At the last visit there was no trace of dis- 
charge. 

It is probably a wise precaution to keep up the irri- 
gation, at more or less frequent intervals, for some 
time after the urethral discharge disappears. The 
patient should be directed to hold her water as long 
as possible before the visit, in order that any trace of 
discharge may be discovered. 



^ EPIDEMIC INFLUENZA AND INSANITY. 1 

BV ARTHUR H. HARRINGTON, M.D., OF DAN VERS. 

When I had the honor of receiving an invitation 
from the chairman of the Medical Section to present 
a paper at this time, it occurred to me that it would 
be pardonable if I referred to some cases which I re- 
ported a few weeks ago at a meeting of the South 
Essex District. 

These cases, which are instances of insanity devel- 
oping together with or after an attack of the influenza, 
may be of interest to you, considered as one of the 
phases of the recent epidemic. In addition to the 
original paper, I have, through the kindness of a num- 
ber of medical gentlemen, been able to obtain some 
useful material upon this subject, so that we shall have 
for our consideration the observations of others rather 
than mine alone. 

In looking over the history of the*various epidem- 
ics of influenza, we find careful descriptions of the 
thoracic, the abdominal, and the nervous types of the 
disease, — under the latter are included the general 
nervous or cerebral disturbances. Now, such cerebral 
disturbances as headache, insomnia, somnolence, de- 
lirium, etc., receive attention ; but, in the literature 
which I have been able to consult, the statements 
touching upon the purely mental disturbances or psy- 
choses are of a most general character. And this is 
my reason for presenting this subject somewliat in de- 
tail, and mainly from a clinical standpoint. 

Before taking up these cases, if you will allow me, 
I should like to remind you of the limitations to which 
one is subject in attempting to assign the cause or 
causes of insanity in a given case. Probably in this 
class of affections the predisposing causes play a more 

1 i;. .i.t brforc (lie Massachusetts Medical Society, June 10, 1890', 
and recommended lor publication by the Society. 



prominent part than in almost any other. This fact 
is often overlooked, no doubt, and many times what 
are put down as the prime causes are really only the 
secondary or exciting. Moreover, it is rarely that a 
single cause can be fastened upon and held responsible 
alone for the mental disturbance. 

These considerations have been kept in view in 
studying these cases, as complete a previous history as 
could be gained was taken of each, and it was found 
that, of the cases at the Danvers Hospital, with one 
exception, — and in this instance the previous history 
was not ascertained, — there existed predisposing 
causes, congenital and acquired, but it seemed quite 
certain that the attack of influenza, with its febrile 
symptoms, its tendency to cause great physical and 
nervous depression, was the final weight which turned 
the scale. 

It was found that a classification based upon the 
previous histories could be made, into which the cases 
fall quite naturally. This classification is not an 
essential one, but is made to facilitate our easy com- 
prehension of the cases. 

I will state that I am indebted for the data of the 
female cases to my colleague, Dr. M. A. Jewett. 

Cases I and II are instances in which the patients 
had been insane, but had recovered. An attack of in- 
fluenza seems to have been the exciting cause of another 
attack of insanity. Case I, a female, aged sixty, has 
had two attacks of acute mania, treated at the Worces- 
ter and Danvers Hospitals. She was well mentally 
and living with her family when attacked with the in- 
fluenza, January 10th. She very soon became rest- 
less, confused, passed into a maniacal state, and was 
admitted to the Danvers Hospital ten days later, where 
she died after a few days from exhaustion. Case II, 
a female patient, aged twenty-three, has had one at- 
tack of acute mania, from which she recovered. She 
was attacked with the influenza, and soon afterwards 
maniacal symptoms appeared. She was admitted to 
the hospital January 9th, where she continued in an 
acutely maniacal state for four days. At the end of 
this time her maniacal symptoms subsided and she be- 
came quite rational. A month after admission she 
appeared to have made a complete recovery. This 
attack must be regarded as presenting all the motor 
excitement of acute mania; but the delirium which 
the patient exhibited was more like that of an acute 
febrile disease. Attention is called in this case to the 
prompt recovery, which begun with the subsidence of 
the acute bodily symptoms. 

Cases III, IV, V and VI are instances in which 
there had existed, for longer or shorter periods, en- 
feebled physical conditions from various causes, and 
whicli were very likely preparing the way for a men- 
tal breakdown, but in which the influenza seems to 
have been the exciting cause of the attack of insanity. 

Case III, a female, aged thirty, has had symptoms 
of phthisis for two years, and last July had a severe 
attack of pleurisy, which weakened her very much. 
In addition to these debilitating causes she had been 
nursing her child for twenty mouths. Her friends 
state that she was completely run down, but never 
showed any signs of insanity until attacked with " La 
Grippe," when she became restless, sleepless, then 
maniacal, refused nourishment and resisted attentions. 
She died from exhaustion and capillary bronchitis 
nineteen days after admission to the hospital. In this 
instance doubtless, phthisis, pleurisy and prolonged 



Vol. CXXIII, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



127 



lactation were contributing causes to an attack of in- 
sanity, which was precipitated by the additional de- 
pressing effects of the influenza. 

Case IV, a domestic, aged twenty-live, has been 
feeling "poorly," nervous and debilitated for two 
months, and left her place on this account. She was 
attacked with the influenza, and was sent to the Bos- 
ton City Hospital, where she became frightened, 
thought some one was going to kill her, and tried to 
jump out of the window. She was sent to the Dan- 
vers Hospital, where she was restless and stubborn 
for a time. At the end of a month she was better, 
though somewhat confused and dull. She was dis- 
charged four months after admission. Her progress 
had been slow, but steady, and she left the hospital 
with a fair chance of making a complete recovery. 

Case V, a male, aged thirty, a native of France, has 
been in the country a few months. When attacked 
with the influenza he developed hallucinations of smell, 
detected a strong odor as of some poisonous substance 
on his pillow, thought the landlady was attempting to 
poison him in order to get his money. He became 
frightened. In order to attract the police and get pro- 
tection he broke his window, shouted for help, and 
fired a pistol into the street. He was committed to 
the hospital December 30th. He was weak and ema- 
ciated, and aside from the pulmonary symptoms of the 
influenza, he was thought to be suffering from phthisis. 
He was quiet and polite on admission, but during the 
evening attempted suicide. The next morning he 
regretted his action, but confirmed the delusions men- 
tioned above. As he recovered from the influenza 
the hallucinations of smell disappeared, and two weeks 
after his admission, while he recognized his actions 
and many of his ideas as foolish, yet he was not able 
to dispossess himself wholl}* of the belief that his land- 
lady had attempted to poison him. This belief re- 
mains like a " fixed idea," and it is not unlikely that 
in this instance the attack of influenza was the excit- 
ing cause of a mental disorder which may become 
chronic. 

From a psychological point of view this case is very 
interesting, as showing the apparent origin of the de- 
lusional ideas in the hallucinations of smell, — these 
latter or at least disorders in olfactory sensation and 
perception being not an uncommon symptom connected 
with the influenza. 

Case VI, a gentleman, aged sixty, was thought to 
have had a slight apoplectic attack two years ago. 
His physical health from that time has been poor, and 
he has been subjected to severe mental strain and worry 
growing out of business affairs. He was much pros- 
trated by an attack of influenza, and did not gain 
strength again, and after three weeks he began to 
show signs of mental derangement, and was sent to 
the Dan vers Hospital. This case proved to be an ex- 
cellent example of acute confusional insanity, a form 
which will be referred to again. The patient's death, 
which occurred in three weeks after admission, was 
due to exhaustion and capillary bronchitis. 

Cases VII, VIII and IX were individuals evidently 
belonging to a well-known class ; the characteristics 
of its members are, that they are the possessors from 
birth of a bad physical organization and are of a low 
grade of intellect. Such persons often break down 
mentally early in life, from comparatively slight 
causes. 

Case VII was a boy, aged seventeen. His mental 



disorder was that of acute confusional insanity. He 
made a rapid and complete recovery, and was dis- 
charged in a few weeks. 

Case VIII. This was another instance of acute 
confusional insanity, in a young woman aged twenly- 
live. Her mental symptoms cleared up to a great 
extent, but she could not be said to have recovered 
fully when discharged. In the last two cases the 
mental disorder developed while the subjects were 
suffering from the acute effects of the influenza, and 
with improving health the mental condition improved 
also. 

Case IX. In a colored woman, aged twenty-five, 
an attack of the influenza was followed immediately 
by acute mania. She was admitted to the hospital, 
and died very suddenly. A post-mortem revealed 
cardiac thrombosis. 

Cases X and XI taken together are interesting. 
At various times they had been given to the excessive 
use of alcoholics. An attack' of the influenza seems 
to have given rise to certain mental symptoms which 
are sometimes observed after prolonged drinking. 
Case X, a male, aged fifty-one, has been a periodic 
drinker for years. When getting over a drinking 
spell he would almost always have a period of pro- 
found depression, and would be suicidal. During one 
of these periods, in 1886, he came near destroying 
himself by cutting his throat, and was at the Dan vers 
Hospital for a time. He was admitted again January 
1, 1890. The statement was that he had been work- 
ing steadily, for several months, up to the time of his 
attack of influenza, and his friends asserted that he 
had not drunk of late. While suffering from the in- 
fluenza he grew sleepless and despondent, took no 
nourishment, then became violent and suicidal. After 
coming to the hospital he remained greatly depressed. 
His death occurred after a few days from capillary 
bronchitis and cardiac complications. The point to 
be noticed in this instance is that an attack of great 
mental depression with suicidal tendency, exactly like 
the attacks which followed his periods of excessive 
drinking, developed simultaneously with an attack of 
influenza. 

Case XI. A young man, aged twenty-seven, has 
been in the habit of drinking a good deal, but has 
never been affected by it mentally. Was attacked 
with the influenza and confined in the house for ten 
days. During this time he had no liquor, but hallu- 
cinations of hearing began to trouble him, and dis- 
turbed him to such an extent that he was sent to the 
Danvers Hospital. The committing physicians also 
stated in their certificate that they thought his mental 
trouble due to the "Grippe." As soon as this patient 
began to improve physically, his hallucinations wholly 
disappeared. Hallucinations of hearing, as we all 
know, are a very common result of prolonged drink- 
ing, but this patient seems never to have suffered from 
them until attacked with the influenza. In this in- 
stance the use of alcoholics had probably made the 
conditions favorable for the development of hallucina- 
tions, and the acute illness seems to have been their 
exciting cause. 

In a recent report of eleven cases of insanity after 
influenza, by Kraepelin, he cites a case in which a man, 
who had been addicted to alcoholic excess, developed 
a typical delirium tremens when attacked by the 
influenza. 

Case XII, the only one of the cases seen at the 



128 



BOSTON MEDICAL AND SURGICAL JOURNAL. [August 7, 1890. 



Dauvers Hospital, whose previous history was not 
ascertained, and in whom no predisposing cause of in- 
sanity was found, was a case of acute confusional 
insanity. He made a complete recovery in a few 
weeks. 

In making a few general remarks upon these twelve 
cases, I will say that the physical as well as the mental 
symptoms were of a very marked character. The pa- 
tients, when admitted, had the facies of an acute ex- 
hausting disease ; there was the great depression of 
the physical forces and the acute bronchitis with a 
profuse muco-purulent expectoration which character- 
ized the epidemic disease. As for the mental symp- 
toms, out of these twelve cases, four were excellent 
examples of acute confusional insanity, and six of the 
remaining cases presented some symptoms which would 
remind one strongly of that type. 

By acute confusional insanity is meant a form which 
resembles acute mania, and, as far as outward appear- 
ances go, might readily pass for acute mania, but at 
the bottom of which there is no emotional disturbance 
as in acute mania, the conceptional sphere is dimmed, 
consciousness is blurred, and patients recovering have 
a crude recollection of their condition. When hallu- 
cinations predominate, this is called by some " acute 
hallucinatory insanity." This form most often devel- 
opes on the basis of acute, exhausting and depressing 
diseases, the very factors which were present in the 
cases which have been cited, and which would account 
for their general leaning towards the type of acute 
confusional insanity. 

Of these twelve cases, those which recovered or im- 
proved did so promptly as soon as the physical condi- 
tion improved. The mortality in the twelve cases 
named was large, and was due to the exhausted condi- 
tion of the patient, together with cardiac and pul- 
monary complications. 

The study of these twelve cases led me to a desire 
to learn the experience of other hospitals during the 
recent epidemic. Accordingly, I sent out a number 
of circular letters, and I received replies from the 
superintendents and medical officers of twenty -two 
institutions. I desire to express my thanks for their 
courtesy in answering my questions so promptly and 
carefully. 

The letter comprised six questions, and the replies 
were both negative and affirmative, aud I will give the 
sum of them very briefly : 

First Question. — In how many cases of insanity 
has the influenza been regarded as the exciting cause ? 

In ten hospitals out of the twenty-two no cases had 
been observed. In the remaining twelve hospitals the 
aggregate number of cases admitted, thought to be 
due to the influenza as their exciting cause, was thirty- 
six. 

Second Question. — In how many of these cases has 
the influenza been the only assignable cause? The 
answer was sixteen out of the thirty-six. 

Third and Fourth Questions. — How many cases 
have recovered, and how many have died? Twelve 
had recovered and two had died out of the thirty-six 
cases. 

Fifth Question. — What forms of insanity have been 
observed ? I give the diagnoses, of course, just as I 
received them, and for convenience will include here 
the twelve cases of the Danvers Hospital. So that 
out of forty-eight cases, seventeen were acute mania ; 
fourteen acute melancholia; five primary confusional 



insanity ; two each of simple mania, simple depression 
and delusional insanity ; one each of acute delirious 
mania, acute febrile delirium, acute dementia, senile 
mania, apoplectic dementia and alcoholic dementia. 

Sixth Question. — Have the mental symptoms as a 
general thing presented any peculiar features due per- 
haps to the influence of the epidemic disease ? The 
answers to this question quite generally bore out some 
observations of my own. Among them I will quote 
the following : 

Dr. C. M. Hay, of the State Asylum at Morris 
Plains, says, "Generally the insanities in these cases 
have been of a very marked type, but whether this 
was due simply to the exhaustion in which the mental 
affection found them or was connected with a specific 
toxaemia I cannot say." Dr. Cowles of the McLean 
Asylum states, " I do not know that the mental symp- 
toms have presented any notable peculiarity except 
the tendency to prompt recovery as if upon the abate- 
ment of some debilitating or depressing influences." 

Another question which might have been asked, 
namely : What effect has the influenza had upon those 
already insane when attacked by it? was suggested 
afterwards by a report of some cases by Dr. Paine of 
the Westborough Homoeopathic Hospital and which 
appeared in the Boston Herald of April 24th. I have 
been referred by Dr. Paine to this report, so I take for 
granted that he was correctly quoted. Dr. Paine, you 
may remember, reported some cases suffering with 
chronic forms of insanity who recovered mentally after 
an attack of the influenza, to which he attributes their 
recovery. 

Unfortunately of the thirty per cent, of the insane 
population at Danvers Hospital who suffered from the 
influenza none seemed to be cured by it. In fact the 
mental symptoms were augmented rather than dimin- 
ished even, remarkably so in four cases. 

Dr. Lyon, of the Bloomingdale Asylum, says, " I 
may add that I have seen no such remarkable cures 
from chronic insanity or any other form, effected by 
the 'grippe,' as I have read of." Dr. Park, of the 
Worcester Hospital, says, " We have had no cases of 
recovery from chronic mania due to ' grippe.' " 

CONCLUSIONS. 

This paper has not aimed to gather the statistics of 
the relation of the recent epidemic of influenza to in- 
sanity. This would be a difficult and uncertain task. 
It is quite likely that in many cases attention was not 
given to the subject, and the most that can be learned 
will probably be found in the annual reports of the 
institutions when they shall be issued. But taking the 
cases of the Danvers Hospital and those reported from 
other hospitals, we have forty-eight cases in which an 
attack of the influenza was followed immediately or in 
a short time by the development of a psychosis. In 
thirty-one cases the influenza acted as an exciting 
cause to iusanity, predisposing and other exciting causes 
being clearly made out. In seventeen cases the influ- 
enza was the only assignable cause of insanity. I 
incline to the belief that if the antecedents of these 
seventeen cases could be thoroughly analyzed, this 
number seventeen, in whom no predisposing causes 
were known, would be diminished aud that we might 
approach nearer a conclusion made by Kraepelin, 
namely : that the influenza alone is not sufficient to 
occasion the development of a psychosis. 

Of the total forty-eight cases, sixteen recovered. 



Vol. CXXIIT, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



129 



Considering that in hospitals the average number of 
recoveries in new cases is only from fifteen per cent, to 
twenty per cent., the recovery of thirty-three per cent, 
of these cases is worthy of remark. 

Cases of insanity excited by the influenza have 
shown a greater tendency to prompt recovery or 
improvement than is usual in recent cases. In most 
instances the improvement has beeu coincident with 
the abatement of the acute bodily symptoms and the 
return to physical strength and health. 

Finally, out of these forty-eight cases, while I cannot 
include them all in a classification, yet it is quite easy 
to recognize three main groups, namely : 

(1) Cases of simple depression and hypochondria. 
Many such instances were no doubt seen by those in 
general practice during the epidemic, but in which the 
mental disturbance did not proceed far enough to 
demand hospital treatment. 

(2) Cases in which the emotional disturbance was 
carried farther than in the first group, resulting in 
acute forms of mania and melancholia. 

(3) A considerable proportion of cases which de- 
veloped on the basis of bodily exhaustion and depres- 
sion of the nervous forces, namely : the cases of 
delirious mania, febrile delirium, and especially those 
of acute confusional insanity, which appears to me to 
be the type towards which the symptoms in many cases 
have inclined. 



HYALINE-FIBROID OVARIAN DISEASE. 1 

BY HENEAGE GIBBES, M.D., 

Professor of Pathology , University of Michigan. 

In January of this year I published a paper in the 
Boston Medical and Surgical Journal, on the "Origin 
of Ovarian Cysts." Since then I have examined a 
number of ovaries, and can now add something to the 
facts stated in that paper. I then gave three causes 
for the origin of cysts in the ovaries: (1) an over- 
growth of normal tissue, supposed to be of embryonic 
character ; (2) dilatation of Graafian follicles ; (3) Hy- 
aline degeneration of the ovarian stromae. Further 
investigation inclines me to think that this latter form 
is a much more frequent cause of ovarian disease, at 
any rate in young patients, than the other two ; and 
I wish to say a few words on this peculiar change. I 
have called it hyaline degeneration ; and from the ex- 
amination of a large number of ovaries removed during 
life, I am convinced that a large majority are affected 
by this change. The term hyaline degeneration con- 
veys no clear impression to the mind of what the 
change is, further than that it is a homogeneous mate- 
rial into which the normal ovarian stroma is trans- 
formed. 

It is important, therefore, to find out the nature of 
the new formation, and then, if possible, its preven- 
tive or cure. To establish its precise nature, I have 
made a number of experiments with reagents, with a 
view to finding out its chemical nature and the normal 
tissue to which it corresponds. I am now satisfied that 
it is not a degeneration, in the strict sense of the word, 
but is a new formation of fibrous tissue of a peculiar 
character. I will not give an account here of the 
numerous experiments I have made, as it would prove 
tedious, but will state their results. In the first place, 
we all know that in whatever condition white fibrous 

1 Read before the Michigan State Medical Association, Grand 
Rapids, June 19, 1890. 



tissue is found normally in the human body, it has 
always associated with it connective-tissue corpuscles; 
and when this tissue is in a young, growing state, then 
these corpuscles will be very numerous. This is also 
seen in rapid new growths of fibrous tissues, such as 
keloid, where the connective-tissue corpuscles are dis- 
tributed in enormous numbers among the rapidly grow- 
ing fibrous tissue. This is exactly what is found in 
the new growth in the ovary. At first, narrow, sinu- 
ous bands of fibrous tissue appear in the ovarian stroma. 
They become larger and many in number, always hav- 
ing the same peculiar, tortuous arrangement. Between 
these bands are numbers of branched connective-tissue 
corpuscles, closely applied to the fibrous tissue. The 
chemical reaction of this new growth is similar to that 
of white fibrous tissue growing rapidly under other 
conditions; and the relation of the connective-tissue 
corpuscles to it is also seen in other normal and abnor- 
mal conditions. I consider, therefore, that I am justi- 
fied in calling this a growth of fibrous tissue of a 
peculiar kind. 

Now this fibrous change is not peculiar to the ovary. 
I have found exactly similar conditions in the lungs in 
tuberculosis, and in slow-growing carcinoma, and an 
almost similar change in slow-growing sarcoma. These 
cases were all of slow growth. The lungs were 
invaded by reticular tubercle; and the disease had 
existed for two or three years. In all there was chronic 
irritation. Now, what we want to know is, What 
caused a new growth of fibrous tissue that, in the case 
of the ovary, could break down to form a cyst. I 
must here state that in all these formations the new 
growth became extensive, and being probably of low 
vitality, with a deficient nutrient supply, the central 
portiou, after a time, broke down, and formed a cavity, 
this filled with fluid, as all cavities in the ovary are 
prone to do, and gradual dilatation took place, ending 
in the formation of a large cyst. 

In a state of nature, unfettered by civilization, the 
human female was probably intended to conceive and 
bear young as other animals do ; and in this way the 
ovary could perform its function at periodical intervals 
with intervening periods of rest, we have, however, 
altered all this. A large majority of women pass 
through that period of their lives when their sexual 
organs are in their highest functional condition, with- 
out there being any opportunity for the exercise of 
these functions. This, of itself, would not prove 
prejudicial to health ; but when uncongenial employ- 
ment and surroundings are added, is it any wonder 
that something goes wrong? 

Women at the present time are pushing more and 
more into conditions of life which are eminently unsuit- 
able to them, but they are forced to do so under existing 
circumstances. Any one who has lived amongst people 
in a semi-savage state, knows how little the females 
suffer from diseases of their sexual organs and what 
an extremely simple matter parturition is. But take 
the everyday life of a working-girl who has, in many 
cases, to be on her feet all day, often in a close, un- 
healthy atmosphere, or under many other conditions 
all more or less unhealthy — this going on during the 
menstrual period, what is the result? A condition of 
anemic dyspepsia ; and after this has existed some 
time, comes leucorrhcea, bearing-down pains, pain in 
the back, etc. Now, if the patient be examined in an 
early stage of this condition, it will generally be found 
that one of the ovaries is enlarged and tender; and in 



130 



BOSTON MEDICAL AND SURGICAL JOURNAL. [Acgcst 7, 1890. 



the majority of cases, it will be the left. The pain 
can often be traced to this ovary, and will be found to 
extend down the front of the thigh, or in towards the 
spine in the lumbar region. This condition of things 
seem to be brought about by an unhealthy condition 
of life reacting on an organ in full functional activity, 
but called on to perform that function continuously and 
without that period of rest intended by nature. 

This is the acute stage, and may exist for a long 
time, but is certain, if not relieved, to become chronic, 
that is, to produce structural change. We know that, 
after a time, an acute disease becomes chronic, and 
produces change in an organ, and that these changes 
vary with the organ and the exciting cause. It is 
therefore quite probable that a long-continued irrita- 
tion, acting on such an organ as the ovary under the 
conditions I have named, would be likely to produce 
those changes which I have found in nine-tenths of the 
ovaries I have examined. 

The organs are also sometimes subjected to abnor- 
mal excitement, both in the married and unmarried, 
which I need only allude to here, but which must be 
very prejudicial to their well-being. In a large out- 
patient practice in London I had abundant opportu- 
nity for studying these cases, and I found no difficulty 
in curing them when taken in time. My treatment 
was first for the dyspepsia, then the anaemia, and con- 
currently with this counter-irritation over the affected 
ovary. I had many cases under observation for years 
with no return of the symptoms. 

I have lately received ovaries from Dr. Minar of 
Bay City, Dr. Mauton of Detroit, and a number of 
others, and they all show this same fibrous change. 
The ovary received from Dr. Minar has, in addition, 
a large cyst lined by columnar epithelium, which I am 
inclined to think is caused by the inclusion of a por- 
tion of the fallopian tube in the hypertrophic growth. 

The ordinary pathological chauge, then, that is 
found in ovaries removed during life, is of the nature 
described. The same change occurring in other con- 
ditions show that the cause is a chronic irritation. 
This irritation, in the case of the ovaries, is probably 
of nervous origin, and is brought about by an abnor- 
mal condition of the patient and her surroundings. It 
also begins in an acute form, which, from an experi- 
ence extending over a number of years among a class 
of women peculiarly liable by their work and everyday 
life to this affection, I have found to be easily curable 
if taken in an early stage. 



REPORT ON OBSTETRICS. 

1SY CHARLES M. GREEN, M.D. 

THE INFLUENCE OF INFLUENZA ON THE FEMALE 
SEXUAL ORGANS. 

When epidemic influenza may again haplessly pre- 
vail, the medical profession will be better informed as 
to its probable effects in causing or modifying other 
phases of disease. Much has been, and more will be, 
written on the immediate and remote results of influ- 
enza; and from many observations will be deduced, 
doubtless, facts of interest and value. 

Muller 1 (Munich) has observed fifty-one cases of 
influenza in women, three of whom were pregnant ; 
and his paper is an interesting contribution to the sub- 
1 CentralblattfUrGynttkologle, 1890, No. n. 



ject. Of the forty-eight cases of influenza in the non- 
pregnant, Miiller believes that the genital affections 
found present when he saw them were induced by in- 
fluenza in forty-six instances : in one case, the sexual 
organs appeared to be in no way affected ; and in one 
other case the epidemic influence on these organs was 
undecided. 

The important symptom by which the epidemic in- 
fluence manifested itself in the non-gravid was profuse 
metrorrhagia, which was characterized by its long 
continuance and great resistance to ordinary measures 
for relief. The bleeding was accompanied by swelling 
and sensitiveness, and enlargement of the uterus. 

In the three gravid cases affected with influenza, 
pregnancy was interrupted in two instances : in the 
third case pregnancy was not in the least affected by 
the disease. The first case, in the eighth week of her 
fourth pregnancy, took sick with mild symptoms of in- 
fluenza, and with the appearance of the first symptoms 
was seized with profuse uterine haemorrhage which 
resulted in abortion. The bleeding was so severe 
from the beginning, that when seen by Miiller she 
showed symptoms of collapse ; and the haemorrhage 
continued profuse for several days in spite of energetic 
treatment. Other causes of the abortion were sought 
for ; but nothing could be found to account for it in 
the history of the three preceding weeks. The ovum 
presented no abnormality. 

The second case was in the eighth month when 
seized with violent symptoms of influenza: there was 
cough, but not of such severity as to have caused pre- 
mature labor by concussion. With the invasion of 
influenza uterine contractions set in which lasted four 
days and finally resulted in the expulsion of the 
fcetus in spite of treatment to prevent it. The loss of 
blood was considerable. The influenza had consider- 
ably diminished in intensity by the end of four days, 
but continued for eight days after delivery. In other 
respects the puerperium was normal, and involution 
was not retarded. 

Both of these cases were multiparous ; but the third 
case was that of a primigravida, who, while in the 
third month, had a severe attack of influenza with 
fever, bronchial catarrh, and almost continuous, severe 
cough. The sickness lasted eight days ; but the preg- 
nancy was in nowise affected. 

MEASLES IN PREGNANCY. 

The occurrence of measles during pregnancy is so 
infrequently observed that the following case, reported 
by Lomer 2 (Hamburg), is of interest : 

A primigravida, aged twenty-two, who had always 
been healthy and had never had measles as a child, ex- 
pected her delivery in the middle of July. On June 
7th, while a severe epidemic of measles prevailed in 
her town, she was suddenly seized with chills, cough, 
fever, burning in the eyes, and diarrhoea. Next day 
labor supervened, and in seven hours she was spon- 
taneously delivered of a premature, living child. When 
seen the next morning, the eruption of measles was 
found on both mother and child : on the mother, dis- 
tributed over the whole body ; on the child, on forehead 
and chest. On the fifth day the mother was taken 
with pneumonia, from which, however, she recovered 
after a long sickness : the child died in four weeks of 
intestinal catarrh. 

Cases of measles complicating pregnancy have been 

2 Control blult fiir Gynitkologio, 1889, 48. 



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131 



seldom described, and the text-books have little to say 
on the subject. Lomer quotes from an article by 
Gautikk, 8 who was able to collect from the literature 
only eleven cases, of which most were of ancient date 
and defectively reported. Among these eleven cases, 
in six was the mother infected during the last month 
of pregnancy, and in all six cases the infants were said 
to have been born with the eruption of measles, or the 
exanthem appeared soon after birth. On the other 
hand, in a case observed by Gautier, the infant was 
horn free from the eruption, which moreover did not 
appear subsequently, although the child was suckled 
by the mother. In the other four cases collected by 
Gautier, the infection led to interruption of the preg- 
nancy, and two mothers died. 

RELAXATION AND RUPTURE Ob' THE PELVIC ARTICU- 
LATIONS. 

Under this title Remy 4 describes two cases observed 
by him. In the first case, a relaxation of the left sacro- 
iliac articulation occurred in the spontaneous labor of 
a very strong girl. The lesion manifested itself by 
acute paiu when the patient attempted to get up : a 
supporting girdle gave great relief ; but a number of 
months were required for permanent cure. [This case 
is not without medico-legal interest as showing that 
injury to the pelvic articulations may occur in non- 
instrumental deliveries.] 

In the second case separation of the pubic symphy- 
sis occurred with a loud cracking sound during forceps 
extraction of a large child through a generally con- 
tracted pelvis. Recovery took place after many months, 
and nineteen months later the patient easily bore a 
child without artificial assistance. 

HEMATOMA VULVAE. 

Ligterink 5 (Kralingen) reports two cases of this 
affection : 

(1) A quintipara had been normally delivered by a 
midwife, after half an hour's labor : the placenta came 
spontaneously, and the uterus contracted well. An 
hour later the woman complained of paiu in the peri- 
neum, radiating to the left leg. Three hours after- 
wards Ligterink found the left labium majus swollen 
to the size of the fist: the tumor was dark blue, the 
skin much stretched and almost transparent. There 
were no varices on the labia majora or legs. The 
uterus was higher than normal and inclined to the 
right : the bladder was empty, and in the left iliac fossa 
there was marked resistance and dulness. On friction 
of the uterus no more blood escaped than is customary 
four hours after labor. 

Vaginal examination disclosed a tumor, which dis- 
tended the left vaginal wall and reached up to the 
fornix. The conjecture that the bleeding had extended 
above the pelvic fascia was confirmed by the increase 
of dulness during the first hour of observation and by 
its persistence in spite of catharsis. The temperature 
was 37.8°, and the pulse 80. The treatment prescribed 
was absolute rest, a vaginal douche with a sublimate 
solution (1 to 3,000), an ice-bladder in the vagina as 
well as on the perinaeum, labium majus, and iliac fossa : 
also ergotin and morphia subcutaneously. 

On the fifth day there appeared on the left labium 
near the posterior commissure a gangrenous spot, 

• Annales de Gynecologie, 1879, p. 321. 

• Arch, de Tocologie, April, 1889 : Centralblatt f. Gyn., 1890, 1. 

c Nederl. tijdschr. voor Geneeskunde, 1889, No. 14; Centralbl. f. 
Gynaek., 1890, No. 5. 



which next day had increased to two inches in diameter : 
a free incision was made at this point, and the cavity 
tamponed with iodoform gauze. Complete recovery 
took place four weeks after labor. 

(2) This case occurred in a non-pregnant woman, 
who, in falling, had struck her perinaeum on the point 
of a wooden shoe. There was no external bleeding 
and no wound ; but two hours later the perinamin 
began to swell and to be painful. Next day Ligterink 
found the right labium majus swollen to almost the 
size of the fist and ecchymosed. The right vaginal 
wall was also involved to the extent of about two 
inches. The same treatment was prescribed as in the 
first case. In due time the tumor emptied itself spon- 
taneously : healing took place in four weeks. 

[Vulvar hsematomata are not of common occurrence 
either during or after labor, although traumatic cases 
may of course occur from any suitable injury. It would 
seem that they would be most commonly observed 
when the labia are the seat of varices. When developed 
inter partum they may cause decided obstruction to 
delivery. The treatment of post partum cases is well 
presented by Ligterink : for although in inter partum 
cases it may be necessary to lay open the tumor in 
order to effect delivery, it is wiser to avoid this when 
possible until the bleeding vessels have become effec- 
tively plugged by thrombosis. In opening the tumor, 
surgical asepsis, with pressure and drainage assured by 
the use of iodoform gauze, constitute the approved 
method of treatment. — Rep.] 

THE FUNIC SOUFFLE AND THE UTERINE BRUIT. 

Ettinger, in his inaugural dissertation, records 
his observations on these points in Breisky's clinic. 
He accurately observed twelve instances of the funic 
souffle, and concluded that in most cases the murmur 
originated in the cord itself from compression of the 
funic vessels, either by coiling of the cord, by knotting, 
or when it was unduly short. He believes that the 
origin of the murmur can be found only exceptionally 
in the foetal heart, and therefore considers the name 
funic souffle a proper one. 

He examined for the uterine bruit in 100 consecutive 
cases, and found it in 88 instances ; — 63 times on the 
left, 12 times on the right, 10 times on both sides and 
3 times anywhere he pleased on the abdomen. The 
reason for the most frequent left-sided seat of the 
bruit lies in the physiological right obliquity and right 
lateral torsion of the uterus. In 60 cases Ettinger 
heard the bruit post partum : the bruit is heard post 
partum most frequently in multiparae. 

inversion of the uterus, following traction 
on the funis. 

Cleveland 7 (New York) has reported to the New 
York Obstetrical Society the following case, which 
carries its lesson with it. Expulsion of the child in 
two or three pains, before the medical atteiidaut 
arrived, — precipitate labor. Gentle traction on the 
cord, combined with gentle massage of the uterus, 
pending which the right cornu uteri was felt to cave 
in, and speedily the uterus, with placenta firmly 
attached, was completely inverted. The whole mass 
was pushed back into the vagina, while the haemorrhage 
was profuse and pain extreme. After some effort the 
uterus was finally replaced, while the patient was 

° Ziirick. 1888 : Centralblatt f. Gyn., 1889. 48. 
7 American Journal of Obstetrics, January, 1890. 



132 



BOSTON MEDICAL AND 



SURGICAL JOURNAL. [August 7, 1890. 



nearly in a state of syncope. Copious intra-uterine 
douches of hot water were then employed. Until the 
moment of using the hot water the uterus was perfectly 
inert and refused to contract in the least. A dose of 
ergot had previously been given. After hot water had 
been injected for a few moments, the uterus began to 
respond ; and after two gallons had been used tonic 
contraction took place, the bleeding ceased, and the 
woman recovered. Dr. Cleveland believed that the 
inversion was due to his traction on the cord, although 
he used no greater force than he thought justifiable. 
In this case, however, when the uterus was inert and 
the placenta adherent to the fundus, he thought the 
slight traction employed was sufficient to cause inver- 
sion. He did not think that the pressure exerted on 
the fundus was sufficient to have any influence in 
causing the inversion in this case. 

In the discussion which followed Dr. Grandin queried 
whether the main etiological cause of the inversion 
was not paralysis of the uterus following a precipitate 
labor, and whether in that case traction on the cord 
would not have caused inversion whether the placenta 
was attached to the fundus or to the side : and he 
further stated that expression of the placenta is not 
called for until it is loosened from its seat, which 
loosening only occurs when the uterus regains tone 
and contracts. 

[Although it is perhaps unnecessary to comment on 
this case, the reporter cannot refrain from ranging him- 
self with Grandin in his views on the management of 
the third stage of labor. There could be no better 
argument than the case reported against ever making 
traction on the cord. It can never be known that the 
placenta is not adherent, until after the normal con- 
tractions of the uterus, supplemented perhaps by arti- 
ficial compression, having failed to extrude the after- 
birth, the hand is passed into the uterus and the actual 
condition ascertained. There being no haemorrhage, 
no haste should be employed in delivering the placenta ; 
but attention should be directed towards awakening 
uterine contractions, either by the gentle friction of 
the fundus with the hand " cupped " over it, or if nec- 
essary with ice. After contractions are excited, the 
uterus may expel its contents spontaneously. If it 
does not after half-a-dozen pains, Crede's method of 
expression employed during a contraction will surely 
extrude the placenta, if it is non-adherent; and if the 
placenta is adherent traction on the cord will most 
surely not deliver it. If, therefore, traction on the 
cord is either dangerous or ineffectual when the 
placenta is adherent, and unnecessary (besides being 
unscientific) when the placenta is detached, why should 
it ever be employed ? ] 



i&epotrtg of £ocietie0, 

SURGICAL SECTION OF THE SUFFOLK DIS- 
TRICT MEDICAL SOCIETY. 

GEORGE H. MONKS, M.D., SECRETARY. 

Regular Meeting, Wednesday evening, April 2, 
1890, Dr. E. H. Bradford in the chair. 

Dr. G. W. Allen presented a communication on 

SOME POINTS IN THE TREATMENT OF GONORRHCEA. 1 

Dr. A. T. Cabot said: I have been very much 
interested in the able presentation of this subject by Dr. 
1 See page 12) of the Journal. 



Allen, and in noticing his extremely thorough treat- 
ment of his cases. It seems to me that one great advan- 
tage he has is in his thorough applications ; he is sure 
that his medicines reach the spot ; and in a great deal 
of the routine practice one is not. The injections for- 
merly given to patients to be syringed into their own 
urethrae were frequently, no doubt, useless, from not 
reaching the seat of the disease. 

The use of nitrate of silver in most cases of 
chronic gonorrhoea I am interested in. It is the 
treatment I have been carrying out. I came to it 
gradually, and am so well pleased with it that I have 
used it in almost all of these cases, and with usually 
very good results. I have made applications through 
the endoscope, and also somewhat by injections, by 
using a syringe such as Ultzmann uses for the pros- 
tate. A one per cent, solution is perfectly free from 
any harm when injected in this way, and in a great 
many of the rather chronic gleets is attended with 
first-rate results. This method saves the urethra from 
the contact of the endoscope, which is more irritating 
than that of the urethral syringe, and is in some cases 
preferable on that account. In the granular condi- 
tion of the mucous membrane I think the treatment 
through the endoscope is the true one. 

Dr. H. W. Gushing : How far does tenderness to 
instruments correspond to diseased areas as demon- 
strated by the endoscope? 

Dr. Allen : I don't thiuk you can depend on that. 
I think the most sensitive part of the anterior ure- 
thra, as a rule, is the floor of the fossa navicularis, 
and perhaps one-half inch or so back of it, but that 
is generally the least inflamed part, as you look 
through the endoscope. In a very large proportion 
of cases the inflammation is most intense about the 
peno-scrotal angle, and at the tip of the bulb it is also 
generally somewhat inflamed. 

Dr. Cushing : That has been spoken of as rather 
a practical point with reference to treatment without 
the endoscope as designating the point at which local 
application should be made. If any such indication 
could be found, as far as routine treatment of cases 
goes it would save considerable time. Of course the 
rational method and the best method of studying the 
changes in the mucous membrane of the urethra is 
through the endoscope. 

Dr. Allen : Klotz says very decisively that ten- 
derness is no indication of the true state of the mucous 
membrane. 

Dr. J. Homans, 2nd : I understood Dr. Allen to 
say he used a ten per cent, solution of nitrate of silver 
through the eudoscope on a plug of cotton ? 

Dr. Allen : Yes. 

Dr. Homans : When you use a solution and inject 
it you seldom go higher than five per cent? 

Dr. Allen : I think you would not go so high as 
that. When used through the endoscope the solution 
is applied to the very spot inflamed, and a very small 
quantity is used. 

Dr. Homans : My idea was that the danger of 
using a strong injection has been considered to be not 
only on account of the chance of inflaming healthy 
mucous membrane, but also a possibility that the 
treatment might produce stricture ; and I merely ask 
for information. It would be my own feeling if I had 
a spot of chronically inflamed mucous membrane inside 
of my urethra, that I should not want a ten per ceDt. 
solution of nitrate of silver to go anywhere near it. 



Vol. CXXIII, No. 6.] BOSTON MUDWAL AND SURGICAL JOURNAL. 



133 



Dr. Allen : You begin with a one per cent, solu- 
tion and go up gradually, and as soon as you begin to 
see much reaction from it you stop. 

Dr. IIomans : Have you had any cases under 
observation for over a year in which you used a ten 
per cent, solution ? 

Dr. Allen: I have, but 1 have not made accu- 
rate measurements of the urethral calibre. I should 
not have the least fear of stricture from the solu- 
tion. 

Dr. Otis : What is the average amount of time re- 
quired for sucli treatment through the endoscope ? 

Dr. Allen : In an ordinary case of simple ure- 
thral inflammation, where there are no complications, 
no stricture formation or glandular implication, I 
should think, on the average, about a dozen sittings 
would relieve the patient of his symptoms and bring 
the mucous membrane pretty near to the normal con- 
dition, so that it would look very different from when 
you first examined it. Instead of being of a deep 
livid red it becomes rosy red, and then rosy pink. 
Klotz says the normal color is pale pink. Griinfeld 
says it is light rosy red. 

Dr. Stone said he had seen a small syringe with 
lanolin as a menstruum used. The exact spot for 
application was determined by the endoscope, and 
then this lanolin syringe was used as Dr. Cabot uses 
the Ultzmann syringe, and deposited the lanolin 
directly over the spot, and in that way avoided the 
irritation of passing the endoscope each time. The 
lanolin seemed to hold to the urethra and to stay much 
better than cocoa-butter pencils, and better than sim- 
ple watery solutions. 

Dr. Irwin : Does Dr. Allen consider the form of 
treatment he has been using for gleet preferable to 
the regular passage of sounds ? Is it any easier for 
the patient? Of course I know that the use of sounds 
is easier for the operator. I have found steel sounds 
very efficacious and generally successful in the course 
of six weeks to two months. I think it requires a 
good deal of skill and considerable practice to use an 
endoscope, and ordinarily I should think it would be 
easier to use the steel sound. 

Dr. Allen : The steel sound is much easier to use, 
and I think it is very valuable. I have used it in con- 
nection with the endoscope. From the steel sound 
alone I have not had such brilliant results. I think 
there is a certain proportion of cases that will not get 
well with the steel sound. Of course there are occa- 
sional cases that will not get well with the endoscope. 
There are some cases of gleet that 6eem to be past 
hope. 

Dr. Irwin : Have you had any experience in using 
the endoscope, or rather urethrascope, where a column 
of air is used to distend the urethra ? 

Dr. Allen : I have never used it, and have never 
seen it used. 

Dr. F. S. Watson : I wish to make a few remarks 
on the subject of Dr. Allen's paper, as it is one that 
interests me much ; and I will limit them to that part 
of his communication which relates to chronic urethritis 
in the male and its treatment. I agree with the 
reader, that for chronic urethritis uncomplicated by 
stricture, the treatment by local applications through 
the endoscopic tubes is that which is the most certain 
and beneficial ; and that of all the agents for this pur- 
pose nitrate of silver is that which (more especially 
where patches of granulation tissue occupy the urethral 



surface) yields the best results ; and I also concur in 
his opinion that in the obstinate cases the best results 
are gained by gradually increasing the strength of the 
Molution up to 10 per cent. The solutions are best 
applied by moistening a small quantity of absorbent 
cotton with them, after it has been wound on a wire 
for the purpose of holding it firmly. I prefer the or 
dinary endoscopic metal tubes of Klotz, or similar 
ones (with lamplight or sunlight for illumination), to 
the electric light endoscope of Leiter-Nitze, because 
the former lights show the more natural colors in the 
urethra. I have never seen any deleterious results 
follow the use of nitrate of silver in the manner de- 
scribed that were referable to its use. 

One of the most difficult matters of judgment in 
connection with the local treatment of chronic urethri- 
tis is that of determining the length of time and fre- 
quency of sittings to be employed in any case. I have 
frequently seen cases where I am sure the disease had 
been perpetuated by the persistence of a regular 
routine treatment of passing sounds twice or more 
weekly, and of daily astringent injections, and perhaps 
in addition, of endoscopic applications. That such 
was the case, was shown by the fact that in many in- 
stances these patients would wholly recover, on substi- 
tuting a mild injection of permanganate of potash, 
omitting all else, or by omitting all treatment and 
sending them to the country or into camp. 

It is well to bear this fact in mind, and to give the 
patient (in whose condition improvement has ceased 
to occur under persistent local treatment after three 
or four months perhaps) a chance away from his doc- 
tor, in good hygienic surroundings. With regard to 
the frequency of local treatment, I think the best re- 
sults are seen when it is repeated twice weekly ; not 
oftener, and frequently less often. It is of advantage 
to pass a full-sized sound as far as the membranous 
urethra immediately before making the application of 
the solution through the endoscope. Sometimes the 
sound should be lubricated with glycerine in prefer- 
ence to fatty substances, as the latter coat the urethra 
and interfere with the effects of the solution. The 
chief benefit derived from this procedure arises, I 
think, from the opening up of the folds of the urethra 
and exposing also the mouths of the urethral follicles 
to the action of the aftercoming drug. 

Dr. Allen's paper covers so thoroughly the ground 
of the subject that I am able to do little more than to 
substantiate his statements, so far as my own experi- 
ence in the same line may do so. 

Dr. Allen : In regard to the use of the stronger 
solutions through the endoscope, as Dr. Watson says, 
you come to it gradually. When I reported a series 
of cases three years ago, a three per cent, solution was 
the strongest I had used, but I found afterward I 
could gradually increase the strength. 

Dr. Otis K. Newell showed a series of stereop- 
ticon slides illustrating the development of 

evacuators for litholapaxt, 

and then exhibited a model of what he considered to 
be the best form of evacuator thus far constructed. 
This was an instrument in which the evacuating canal 
is uncomplicated by a trap, the evacuator itself, with 
its receiver, acting as one, and for which the principle of 
short urethral measurements makes the tubes anywhere 
from four inches (in children) to six or eight inches in 
length. 



134 



BOSTON MEDICAL AND SURGICAL JOURNAL. [August 7, 1890. 



Dr. A. T. Cabot said : This subject of evacuators 
is a large oue, and one that we cannot, in the time left 
us, discuss at full length, and I, therefore, propose to 
speak only of one or two points ; and I wish especially 
to consider the particular point in which Dr. Newell 
makes his evacuating tubes differ from those in use by 
other operators, namely, that of length. Before speak- 
ing theoretically upon the subject, I wish to state as an 
actual experience that since my attention has been 
called to the question of short tubes, I have had eight 
or nine cases in which the ordinary straight tube of 
Dr. Bigelovv's was entirely swallowed in the urethra 
before the end of the tube reached the floor of the 
bladder where it ought to rest. If I had been at such 
a case without my tubes of full length, I should have 
been unable to finish the operation. It is very im- 
portant in manipulations inside of the bladder, in 
order that you may have delicacy of perception as to 
what you are about, to have an instrument which is 
not firmly held in the soft parts outside of the bladder. 
If you take too short a tube, it may be impossible to 
tell whether the point of the tube has reached the floor 
of the bladder, and how hard it is pressing upon it, 
owing to the resistance of the soft parts which the tube 
puckers in front of it. 

The ideal position is to have the point of the tube 
gently pressing the floor of the bladde'r, depressing it, 
as shown in the casts by Dr. Bigelow, in order that 
there may be a dependent point into which the frag- 
ments fall ; and it seems important not to have a tube 
so short that the pressure against the parts outside of 
the bladder prevents properly estimating the pressure 
against parts inside of the bladder. If I am right in 
this, the ideal condition would be to have sets of tubes 
from which we might select a particular length for 
each case, a length sufficient to just reach the floor of 
the bladder at the time that the soft parts in front are 
beginning to be pressed upon. That would be a very 
cumbrous set of instruments to carry about to opera- 
tions, and, therefore, as a matter of convenience, I 
think most surgeons carry one length, and select a 
length which is competent for all cases. The length 
of Dr. Bigelow's evacuating tube is materially added 
to by the introduction of two stop-corks. These I 
think more important as adding to the comfort of the 
operator than of disadvantage as lengthening the oper- 
ation. In the operation of litholapaxy, lasting an 
hour, I suppose the evacuator is not used one-quarter 
of an hour. The greater part of the time is occupied 
by the lithotrite. Perhaps by shortening the tube we 
could diminish it a few minutes. This would be a 
certain advantage, and yet in an operation of one hour 
the addition of five minutes is of comparatively slight 
importance as compared with any discomfort to the 
operator. 

Another difficulty with the short tube is that it 
brings the evacuator down in very uncomfortable prox- 
imity to the patient's thighs. Any slight movement 
of the patient might disturb the operation ; and in Dr. 
Newell's last evacuator, it seems to me that when the 
penis is pressed down and the stop-cock brought very 
close to the pubes, the receiver in which you want to 
see the fragments falling will be down deep between 
the legs where it would be very difficult to manipulate 
the instrument or to see the fragments fall. 

I think Dr. Newell's point that the curved tube is 
often of advantage was well taken. In some cases in 
which the straight tube fails to bring fragments, upon 



introducing the curved one, it immediately gets them. 
I think that it is a common plan to elevate the pelvis. 
It is one I have used a long time. I think Dr. Newell 
will remember a case on which I operated in Provi- 
dence, with his assistance, in which, when the stone 
was not easy to seize, I elevated the pelvis with a pil- 
low and reached the stone with perfect ease. 

Dr. M. H. Richardson : I have not crushed many 
stones, but I agree with Dr. Cabot that very little 
time is necessary in washing out fragments. The 
greater part is required for crushing the stone. 

It always seemed to me that Dr. Bigelow's instru- 
ment was a very perfect one. The largest stone I 
have crushed weighed about one-quarter of a pound. 
The operation of crushing and removing the fragments 
was less than oue hour, and the greater part was nec- 
essary in crushing the fragments. 

I have had no experience in introducing these short 
tubes, but it always seemed to me that the long straight 
tube or curved tube was more easily introduced when 
you made the urethra tense by pulling on the penis. 

Dr. F. S. Watson : I see Dr. Newell's new evacu- 
ator for the first time to-night, and so do not feel com- 
petent to judge of its merits. The only objectiou to 
its form which occurred to me, is that which Dr. Cabot 
has already pointed out, namely, that the angle of the 
tube to the bulb and bottle below it is so acute that it 
seems as if the bulb would lie inconveniently between 
the patient's thighs. 

Of Dr. Newell's original evacuator, and of the rise 
of the short tubes in connection with it, I have already 
spoken on former occasions, and can only repeat in 
brief what 1 said then. The advantages I have found 
in it are its lightness and the form of its stop-cocks. I 
cannot follow Dr. Newell wholly as to the desirability 
of his short tubes, but have adopted a length between 
the long ones formerly in use and his short ones, which, 
for cases in which there is no lengthening of the pas- 
sage into the bladder from prostatic hypertrophy or 
other cause (which does require the full ordinary length 
of tube), I think is of advantage in facilitating the 
evacuation of fragments. 

I do not think the form that Dr. Newell has given 
to the distal end of his tubes is a good one, as it seems 
to me likely to do damage to the prostatic urethra, 
especially in cases where a median enlargement of that 
organ makes it difficult to enter the bladder; and in- 
jury to that portion of the canal is one of the most 
dangerous accidents, so far as I have observed, that 
can happen in the operation of lithotrity. 

With regard to the relative length of time that 
should be occupied by crushing and evacuating, I agree 
with Drs. Richardson and Cabot, and consider that 
the crushing is much the more difficult and delicate 
step of the two. 

Dr. Newell : I think the whole ground with refer- 
ence to this matter is covered by the fact that a thing 
is sure to live on its merits. 

I am surprised that Dr. Cabot thinks that the pump- 
ing is the shortest part of the operation. I should not 
say that at all. The greater part of the time is con- 
sumed in evacuating. In my own cases, which num- 
ber two, I found that the tube was sufficiently long, 
and that the tactile sense is good, if you do not have 
too large a tube. I think it a great mistake to use too 
tight instruments. It is one of Ultzmanu's points that 
litholapaxy should be a bloodless operation. 

I remember that Dr. Cabot elevated the pelvis of 



Vol. CXXIII, No. 6.] BOSTON MEDICAL AND SURGICAL JOURNAL. 



135 



tho patient whom he has referred to, but I think it is 
not the rule to do so here. Ultzmann insi